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FEVERS: 



DIAGNOSIS, PATHOLOGY, 



AND 



TREATMENT. 



PREPARED AND EDITED, WITH LARGE ADDITIONS, 



FROM THE ESSAYS ON FEVER IN 



TWEEDIE'S LIBEART OF PRACTICAL MEDICINE. 



BY 

MEREDITH CLYMEB, M.D., 

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE FRANKLIN MEDICAL 

COLLEGE OF PHILADELPHIA ; 

CONSULTING PHYSICIAN TO THE PHILADELPHIA HOSPITAL J 

FELLOW OF THE COLLEGE OF PHYSICIANS 5 

ETC. ETC. 








PHILADELPHIA: 

LEA AND BLANCHARD. 

1846. 

ft* 



Entered according to the Act of Congress 3 in the year 1846, by 

LEA AND BLANCHARD, 

in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



&5 



PHILADELPHIA : 
K. AND P. G. COLLINS, 
PRINTERS. 



PEEFACE 

OF THE AMERICAN EDITOR 



The want of a distinct treatise on Fevers, embodying the received 
doctrines of their pathology and treatment, has been long felt and 
generally acknowledged. To supply this deficiency in medical 
literature is the object of the present volume. It has been prepared 
from the Essays on Fever contributed by Drs. Christison, 1 Shaf- 
ter, 2 Burrows, 3 Gregory 4 and Locock 5 to Dr. Tweedie's " Li- 
brary of Practical Medicine," and will be found to embrace the 
whole class of Idiopathic Fevers — Continued, Periodical, Eruptive 
and Puerperal. The additions of the Editor — amounting to about 
one-half of the volume — have been chiefly made with reference to 
the fevers of this country. It has been his aim to render the work 
as complete as possible, and to adapt it particularly to the neces- 
sities of the American practitioner. 

The additional matter is distinguished by brackets, thus [ ]. 

M. C. 

230 Spruce Street, 
1st Mat, 1846. 

1 Robert Christisost, M. D., Sec. R. and Lecturer on the Practice of Medicine 
S.E., Professor of Materia Medica in at St. Bartholomew's Hospital, &c. 

the University of Edinburgh, &c, Presi- 4 George Gregory, M.D., Physician 

dent of the Royal College of Physicians, to the Small-pox and Vaccination Hos- 

&c. pital, &c. 

2 Thomas Shapter, M. D., Physician 5 Charles Locock, M. D., Consulting 
to the Exeter Dispensary, &c. Physician to the Westminster Lying-in 

3 George Burrows, M.D., Physician Hospital, &c. 



CONTENTS. 



Page 

Preface of the American Editor, -------- iii 

CHAPTER I. 

General Doctrines of Fever, (Dr. Christison,) 17 

I. Definition, ----------- 17 

II. Forms of Fever, 29 

III. Local Diseases in Fever, 38 

IV. Nature of Fever, 39 

IV. Exanthematous or Eruptive Fevers, 71 

V. Classification of Fevers, 73 

CHAPTER n. 

Continued Fever, (Dr. Christison,) - - - 74 

I. Symptoms of Continued Fever, 74 

A. Ephemeral Fever, 75 

B. Synocha, or Inflammatory Fever, - 77 

C. Synochus, or Typhoid Fever, 100 

D. Typhus, 102 

II. Secondary Affections in Continued Fever, 113 

III. Sequelae, 133 

IV. Prevalence, Duration and Mortality, 139 

V. Anatomical Characters, .-._._.. 149 

VI. Causes, 157 

VII. Prognosis, 191 

VIII. Treatment, - - - 200 

IX. Prophylaxis of Continued Fever, 232 

CHAPTER III. 

Tiphoid Fever, (Dr. Clymer,) - - - - 234 

I. Definition, 234 

II. Anatomical Characters, ---- 235 

III. Secondary Lesions, --------- 238 

IV. Symptoms, ----- 239 

II. Convalescence, 249 

III. Varieties, 250 

IV. March, 250 

V. Duration, &c, 250 

VI. Complications, - 251 

V. Differential Diagnosis, .___ 252 

VI. Prognosis, 253 

VII. Causes, 255 

VIII. Treatment, 256 

IX. Identity of Typhus and Typhoid Fever, 259 

X. Typhoid Fever of Children, 266 



VI CONTENTS. 



CHAPTER IV. Page 

Plague, (Dr. Shapter,) .... 268 

I. Symptoms, 268 

II. Varieties, 276 

III. Sequelae and Complications, - 282 

IV. Anatomical Characters, --------- 283 

V. Diagnosis, 288 

VI. Prognosis, ... - 289 

VII. Statistics, 290 

VIII. Nature of Plague, 296 

IX. Causes, -- 298 

X. Prophylactic Measures, - 309 

XI. Treatment, 310 



CHAPTER V. 

Yellow Fever, (Dr. Shapter,) - - - 314 

I. Symptoms, - . - . 315 

II. Anatomical Characters, 334 

III. Statistics, - 341 

IV. Prognosis, 344 

V. Diagnosis, ..._„_ 346 

VI. Nature, - - 349 

VII. Causes, 352 

VIII. Treatment, 363 



CHAPTER VI. 

Intermittent Fever, (Dr. Shapter,) - - - 372 

I. Premonitory Stage, --372 

II. Symptoms of the Paroxysm, -------- 373 

III. Complication with Local Affections, - - - - - - 388 

IV. Diagnosis, 393 

V. Prognosis, 394 

VI. Anatomical Characters, - 396 

VII. Statistics, 399 

VIII. Nature, 403 

IX. State of the Blood, 403 

X. Exciting Causes, ---- 404 

XI. Treatment, - 405 



CHAPTER VII. 

Remittent Fever, (Dr. Shapter,) - - - 415 

I. Symptoms, 416 

II. Varieties, -.....--«.. 422 

III. Complications, - 431 

IV. Terminations, 432 

V. Anatomical Characters, -■ 433 

VI. Duration, 435 

VII. Prognosis, 435 

VIII. Nature, 437 

IX. Diagnosis, - 438 

X. Treatment, 439 



CONTENTS. Vll 



CHAPTER VIII. Page 

Infantile Gastric Remittent Feveb, (Dr. Locock,) - 448 

I. Acute Infantile Remittent Fever, 449 

I. Symptoms, 449 

II. Causes, 452 

III. Diagnosis, - 453 

IV. Treatment, 455 

II. Chronic Infantile Remittent Fever, 457 

I. Symptoms, 457 

JI. Treatment, 459 



CHAPTER IX. 

Hectic Feveb., (Dr. Christison,) - . . 462 

I. Symptoms, 462 

II. Diagnosis, 465 

III. Causes, 465 

IV. Treatment, 467 



CHAPTER X. 

Smael-Pox, (Dr. Gregory,) 469 

A. Variola Benigna Discreta, 470 

I. Incubation, 470 

n. Initiatory or Eruptive Fever, 470 

III. Maturation, 472 

IV. Anatomical Characters of the Variolous Vesicle, ... - 473 
V. Desiccation and Decline, - - 474 

B. Variola Confluens, ... - 475 

C. Variola Semiconfluens, 482 

D. Variola Corymbosa, or Coherent Small-pox, - t 483 

E. Variola Maligna, 483 

F. Variolse Anomalse, .-----.-. 484 

G. Variola Confluens Mitigata, 485 

H. Variola Varicelloides, 486 

I. Febris Variolosa Sine Eruptione, -----. 486 

II. Diagnosis, 487 

III. Prognosis, -- 488 

IV. Mortality, 490 

V. State of the Blood, 492 

VI. Anatomical Characters, 493 

VII. Causes, 497 

VIII. Treatment, 502 

Variolous Inoculation, 510 

I. History, 510 

II. Practice of Inoculation, 513 

III. Value of Inoculation, 515 

Vaccination, 518 

I. History, 518 

II. Phenomena, 521 

III. Theory, 523 



Vlll CONTENTS. 



CHAPTER XI. Page 

Measles, {Dr. George Burrows,) - - - 531 

A. Rubeola Vulgaris, 532 

B. Rubeola Sine Catarrho, - 534 

C. Rubeola Maligna, 534 

II. Complications, 536 

III. Sequelae, 537 

IV. State of the Blood, 538 

V. Anatomical Characters, 538 

VI. Diagnosis, 539 

VII. Prognosis, 539 

VIII. Causes, - 540 

IX. Treatment, 543 



CHAPTER XII. 

Scarlet Fever, {Dr. George Burrows,) - 546 

I. Varieties, 546 

A. Scarlatina Simplex, 547 

B. Scarlatina Anginosa, -------- 549 

C. Scarlatina Maligna, -------- 551 

D. Scarlatina Sine Exanthemate, 553 

II. Sequelae, 553 

III. State of the Blood, - - 557 

IV. Anatomical Characters, - 558 

V. Causes, 559 

VI. Diagnosis, - - - -- - - - - - - 561 

VII. Prognosis and Mortality, .-- 561 

VIII. Treatment, - - - - - 563 

IX. Prophylaxis, 568 



CHAPTER XIII. 

Puerperal Fevers, {Dr. LococJc,) - - - 570 

A. Acute Puerperal Peritonitis, - - 577 

I. Symptoms, -- 577 

II. Anatomical Characters, - - 578 

III. Treatment, - - 578 

B. The Adynamic, or Malignant Puerperal Fever, - - - 581 

I. Symptoms, r - 5 ^1 

II. Anatomical Characters, - 583 

III. Nature, 583 

IV. Treatment, 585 

C. Puerperal Intestinal Irritation, 489 

I. Symptoms, 489 

II. Anatomical Characters, 590 

III. Diagnosis, 591 

IV. Treatment, - 591 

D. False Peritonitis, - - ■ 593 

I. Symptoms, 594 

E. Milk Fever, 596 

I. Symptoms, - - - 597 

II. Treatment, 597 



DISSEBTATIONS ON FEVERS. 



CHAPTER I. 

GENERAL DOCTRINES OF FEVER. 

I. DEFINITION. 

[Syn. Pyrexia, Pyrexis. Febris. Fievre, Fr. Fieber, Germ. Febbre, Ital.] 

Fever (febris from fervere, to glow, to be hot*) is so named 
from one of its most prominent symptoms — a sense of increased 
heat. 

The term has a double signification, both in nosographical and 
in familiar professional language. For sometimes it is applied, 
especially in the plural number, to all febrile diseases, including 
primary fevers, eruptive fevers, and acute local inflammations. 
And at other times it is used, particularly as a singular noun, to 
denote primary fevers only, or fevers proper ; while, for embracing 
the whole class of febrile diseases, the more generic term Pyrexiae 
is commonly employed ; which, however, according to its original 
meaning, (from Ttvpeoa^febricito, derived from xZp, ignis\,) does 
not essentially differ from the more specific term, fever. 

It is in the restricted signification, implying those febrile dis- 
eases where the pyrexia is simple, or not combined, at least 
necessarily, either with eruptions of the skin, or with local inflam- 
mation, that the subject of fever will be here in the first place 
considered. 

Fever has been variously defined. Probably no better defini- 
tion can be found than the following, a modification of that 
sanctioned by Cullen : — After a preliminary stage of languor, 

[* Fever, febris, from fervere, to boil; or from fervor, effervescence, because it was 
supposed that the humors in fevers were in a state of motion similar to that of 
liquids in ebullition. Others derive the word from februare, to purge, to purify y 
because fever was regarded by many physicians as a salutary operation of 
nature.] 

[t Pyrexia, used by the Greeks to designate fever, is derived from itv^, irvprhf 
fire, expressive of the heat; which is one of the predominant characters of the 
febrile state.] 
2 



18 GENERAL DOCTRINES OF FEVER. 

weakness and defective appetite — acceleration of the pulse, 
increased heat, great debility of the limbs, and disturbance of 
most of the functions, without primary local disease. It is a 
singular instance, however, of the extreme difficulty of arriving at 
correct nosographical definitions, that scarcely any one of the 
characters here assigned is absolutely invariable ; nor is it likely 
that any other definition will be found, which is not subject to the 
same defect. 

[A definition is wholly inadequate to convey a suitable idea of 
the morbid phenomena, which, in the aggregate, constitute Idio- 
pathic Fever ; as it is impossible for it to embrace all the forms 
and varieties they may assume. A description is much more 
likely to effect it. To attempt this, the most constant, as well as 
prominent characters, should be selected, and separated from the 
subordinate or contingent phenomena. The essential symptoms 
being thus ascertained, the physician is enabled to detect the 
disease, whatever shape it may assume ; or to distinguish it from 
any affection for which it might be mistaken, Few of the phe- 
nomena are constant, or are present in all the stages of the disease ; 
and the characteristic features vary much in degree, and in the 
manner of association. Dr. Copland thus describes Idiopathic 
Fever : — "It commences with debility and lassitude, which are 
followed by chills or rigors ; it is generally composed of several 
invasions or exacerbations ; it implicates the whole of the vital 
endowments and faculties, the fluids, and the entire organiza- 
tion ; it is acute and dangerous in its course, ivith lesion of the 
circulation, with alteration of the animal heat and of the 
secretions, and ivith diminution of vital power; and it is ver- 
satile as to its symptoms and type, with efforts at sudden 
changes or crises" — [Diet. Pract. Med., Am. Ed., by Dr. Lee, 
p. 1041.) 

Debility and lassitude [malaise, fatigue, courbature), are 
among the earliest and most constant symptoms. They are 
obviously the effect of some debilitating or depressing influence 
acting on the nervous system. There is an absolute aversion to 
all mental and corporeal exertion ; together with general unplea- 
sant and peculiar sensations — as precordial anxiety ; restlessness ; 
creeping chills along the spine ; horripilations, &c. ; alternating 
with flushings of heat, with hurried, or suspirous breathing. 

Quickened circulation and increased animal temperature 
have been regarded, by most writers, as the most constant as 
well as salient phenomena of fever, and probably with justice. 
Though in some fevers the pulse may be, at times, slower than 
in health, they are to be regarded as transient, and rare excep- 
tions, easily explicable by reference to existing disorders of inner- 
vation, and by no means diminishing the general value of increased 
rapidity of the pulse in the diagnosis of fever. The temperature 



v DEFINITION. 19 

of the body is variously altered in the different stages of fever. 
There may be increased heat from the commencement ; though 
generally the feeling of cold is experienced at the period of inva- 
sion; which, however, may be nothing more than a morbid 
sensation of the patient— the hand of the physician, applied to the 
surface, at the moment of complaint, detecting an increase instead 
of diminution of heat ; and the mercury, in a thermometer 
placed in the axilla, rises several degrees. The elevation of tem- 
perature is variable. It is felt by the patient; and is detected by 
the physician placing his hand upon the body. The thermometer 
in the axilla, indicates, too, an increased temperature of from 1° 
to 5°. The sensation of heat felt by the patient is not always in 
proportion to the actual rise of temperature. It is not, however, 
a mere increase or diminution of heat which constitutes the whole 
of this phenomenon ; but a peculiar, a morbid alteration of tempe- 
rature, hardly admitting of description. There is more or less 
derangement in the secreting and exhaling functions, indicated by 
the anorexia, thirst, state of the secretions and excretions, and 
the hemorrhages which occur. The paroxysmal character of 
fever is evident in all its forms, whether we regard the regular, 
well-marked paroxysms of intermittent and remittent, or the per- 
petual exacerbations of continued fever. It will be shown here- 
after, conclusively, it is hoped, that fever involves all the functions 
and all the constituents of the body. Critical changes or crises 
are of constant occurrence in idiopathic fever, giving the idea of 
a depuratory effort of nature — favourable changes frequently 
supervening. The character of fever is mutable, presenting ever- 
varying forms and varieties. "Fever," says Dr. South wood 
Smith, " is a genus consisting of several species, and each species 
presents many varieties. The external characters of these varie- 
ties and the internal states upon which they depend, are so 
opposite, that no two diseases in any two parts of the catalogue 
of nosology present a more diversified appearance, or require a 
more varied treatment, than may be the case with two different 
types of fever. The fever of one country is not the same as the 
fever of any other country; in the same country, the fever of one 
season is not the same as the fever of any other season ; and even 
the fever of the same season is not the same in any two indi- 
viduals. Many of the circumstances which constitute these 
varieties in the fevers of different seasons and of individual per- 
sons, are slight and trivial; but some of them are of the greatest 
possible importance, and those diversities, especially, which dis- 
tinguish the fevers of different climates, are intimately connected 
with the causes, whatever they be, which render the disease mild 
or severe, and, consequently, comparatively innoxious or fearfully 
mortal. 

" Something there is, however, which, amidst this astonishing 



20 GENERAL DOCTRINES OF FEVER. 

diversity, preserves the identity of the disease so completely and 
so obviously, that there never has existed any dispute about that 
identity, under any aspect which it has hitherto been observed to 
assume ; so that all physicians, without exception, unhesitatingly 
accord the name of fever to the mildest form of the common fever 
of this country, to the yellow fever of the West Indies, and to the 
plague of Constantinople and of Egypt." — ( Treatise, #c, p. 37.) 

Dr. Smith goes on to remark, that if three persons, each exhi- 
biting an exquisite specimen of one of the several forms of the 
disease, were brought into the same ward of an hospital, the 
external aspect exhibited by each would be so different, that an 
ordinary observer would fail in discovering any common property, 
yet the physician would pronounce them at once to suffer from 
fever. To establish this identity in the professional eye, under 
such a diversity of aspect, there must be particular phenomena, 
common to all the varieties and combinations of the disease. To 
ascertain these essential phenomena has been the object of all 
writers on the subject from Hippocrates to the present time. But 
little success has, however, attended these efforts, though the 
acutest minds in the science have been applied to the analysis. 
The exposition of Dr. Southwood Smith on this subject — in 
which some of the errors of those who have pursued this path ' 
of inquiry, are pointed out, and the proper mode of investigation 
indicated — is so able and lucid, that we shall offer no apology for 
transferring it to our pages. 

" This total failure of men, all of them of unquestionable acute- 
ness, and some of them of splendid genius, in their attempts to 
discover the common phenomena of fever, affords a strong pre- 
sumption that they have not pursued their object in the right path. 
Without doubt, before it is possible to succeed in any scientific 
investigation, it is necessary to form a distinct conception of the 
object of inquiry. Fever is not an entity, not. a being possessing 
a peculiar nature ; and the object of investigating it, is not to dis- 
cover in what such nature consists, or what it is that constitutes 
its essence ; but fever is a series of events, and the object of 
inquiry is to discover what the events are ; what the events are 
that invariably concur in the series ; and in what order they con- 
stantly succeed each other. When we have discovered this, we 
have ascertained all that we can ever know of what is termed the 
nature of fever, as it is this, and only this, that we can ever know 
of any object or process. Every natural object consists either of 
one single substance, or of several substances united ; and our 
knowledge of that object is complete when we have ascertained 
what that single substance is 3 or what all the separate substances 
are that combine to form it. Every natural process consists of a 
number of events, and our knowledge of that process is complete 
when we have ascertained the events themselves, the order of 



DEFINITION. 21 

their succession, and the events to which they give occasion. 
We can make no real progress in knowledge unless we keep 
steadily in view the kind of information which it is possible to 
acquire, and which it is to our purpose to seek ; and dispossess 
our minds of the phantoms which have so long enthralled and 
abused them. 

In relation to our present subject, then, the first object of 
inquiry is, what are the events which invariably concur in fever? 

Where shall we look for the events ? Not in the symptoms. 
Symptoms are not events ; they are only indications of events ; 
symptoms depend upon states of organs ; they are the external 
and visible signs of internal, and, for the most part, as long as life 
continues, invisible conditions. It is then to the state of the organs 
that we must look for the events of which we are in search. 

Are there any states of any organs that always exist in fever ? 
Are the states constant ? Are the organs affected constant ; and 
can both be ascertained ? If this can be truly answered in the 
affirmative ; if it can be proved that there are certain conditions 
of certain organs which invariably exist in fever, in every type, 
in every degree, in every stage of it, we shall have arrived at a 
satisfactory conclusion relative to the first part of our inquiry. 
• The evidence is as complete as observation during life and 
inspection after death can make it, that a morbid change does 
take place in a certain number of organs in every case of fever, 
from the most trivial intermittent to the most alarming continued 
fever, from the mildest plague to the most malignant typhus ; that 
at the two extremes of this scale, and at all the intermediate gra- 
dations of it, there are certain organs which are always affected, 
and that the affection in all is similar. 

The identity of the organs is inferred from the indications 
they give of disordered function during life ; the identity of the 
affection is inferred from the similarity of morbid appearances 
which they exhibit on examination after death. 

The organs affected are those which constitute the nervous 
system ; those which constitute the circulating system, and those 
which constitute the systems of secretion and excretion. The 
spinal cord and the brain ; the heart and the arteries, especially 
their capillary extremities ; the secreting and the excreting organs, 
which, in fact, are composed, essentially, of the capillary extre- 
mities of the arteries ; the secreting and the excreting extremities 
of these arteries, especially as they terminate in the external skin, 
and in the mucous membranes which form the internal skin, this 
is the chain of diseased organs, derangement in the nervous and 
sensorial functions ; derangement in the circulating function ; 
derangement in the secretory and excretory functions, this is the 
circle of morbid actions. 

There never was a case of fever in which all these organs and 



22 GENERAL DOCTRINES OF FEVER. 

affections were not more or less in a morbid state ; there never 
was a concurrence of this morbid state, in this complete circle of 
organs, without fever. The events which invariably concur in 
fever, then, are a certain deviation from the healthy state in the 
nervous and the sensorial functions ; a certain deviation from the 
healthy state in the circulating function ; a certain deviation from 
the healthy state in the functions of secretion and excretion. A 
deviation from the healthy state in one circle of actions will not 
present the phenomena of fever ; a deviation from the healthy 
state in two circles of action will not present the phenomena of 
fever ; there must be a deviation in the three circles before fever 
can exist. Such, then, are the common phenomena of fever. 

For obvious reasons the detail of the proof that these several 
events really and invariably take place, must be postponed until 
the phenomena themselves have been stated, or what is termed 
the history of the disease has been given. 

But it is not the invariable concurrence of a particular number 
of events that is alone sufficient to constitute fever; to this must 
be added invariableness of concurrence in a particular order. As 
will be shown in the proper place, there is complete and irresisti- 
ble evidence that these events do occur in one invariable order. 
Derangement in the functions of secretion and excretion never 
comes first in the series; derangement in the nervous and sen- 
sorial functions never comes last in the series; derangement in the 
function of the circulation never comes either the first or the last 
in the series, but is always the second in succession. 

The order of events then is, first, derangement in the nervous 
and sensorial functions; this is the invariable antecedent: secondly, 
derangement in the circulating function; this is the invariable 
sequent ; and thirdly, derangement in the secreting and excreting 
functions; this is the last result in the succession of morbid 
changes. 

Supposing the matter of fact to be as is here stated, and the 
proof that it is so will be adduced hereafter, it is clear that we are 
in possession of the true characters of fever. We know the 
events ; we know the order in which they occur ; we know, there- 
fore, what it is that constitutes the disease, and we know, conse- 
quently, what it is by which it is distinguished from every other 
malady. No other disease exhibits the same train of phenomena 
in the same order of succession. In inflammation some of the 
phenomena are the same ; but the order in which they concur is 
not the same ; and this affords a clear and universally applicable 
mark of distinction between fever and inflammation. In inflam- 
mation there is similar derangement in the secreting and excreting 
functions ; there is also sometimes similar derangement in the 
circulating function; but the derangement in the nervous and 
sensorial functions is seldom, if ever, similar ; the derangement 



DEFINITION. 23 

that does take place in these latter functions, while it is apparently- 
different in kind, is certainly and invariably different in the order 
of its occurrence. In pneumonia, in enteritis, in hepatitis, the 
spinal cord and the brain are never the organs in which the first 
indications of disease appear ; the earliest indications of disease 
that can be disco verecLhave their seat in the affected organ itself; 
it is only after the disease has made some progress that other 
organs and functions are involved ; and, apparently, the last to be 
involved, and certainly the least to suffer, is the nervous system. 

We can now, then, answer the questions so often asked— are 
fever and inflammation the same ? and if not the same, in what 
do they differ? Fever and inflammation are not the same, be- 
cause the term fever is appropriated to the designation of a certain 
number of events which occur in a certain series ; the term inflam- 
mation, on the other hand, expresses another series of events, 
each event composing this train, succeeding each other in a differ- 
ent order ; and the difference between the two series of events is 
precisely this difference in their individual phenomena, and in 
their order of succession. What the physical and the physiolo- 
gical condition of the organs is, as contrasted with their condition 
in the state of health, has not yet been made out with regard 
either to fever or to inflammation ; in the present state of our 
knowledge, therefore, we can neither affirm nor deny anything 
respecting either the identity or the difference of that physical 
and physiological condition of the organs in these two classes of 
disease. What inflammation is beyond the series of events we 
are able to observe, we do not know ; what fever is beyond the 
series of events we are able to observe, we do not know ; we com- 
pare the events and we see that they differ ; and since the use of 
names is to mark and to express differences, it is right to distin- 
guish these different events by different terms. But though in the 
present state of our knowledge, we are not justified in considering 
fever and inflammation to be the same, yet the close, perhaps 
the constant connection between them, is a fact of the utmost 
importance to be known, and requires to be incessantly before 
the view of the practitioner. And of this we shall have but too 
abundant evidence in the sequel. 

Supposing the proofs hereafter to be adduced to be conclusive, 
that the events in fever and their order really are what has now 
been stated, how clearly and beautifully does this view of the dis- 
ease enable us to recognize one and the same malady through all 
the modifications it undergoes, and, therefore, through the count- 
less aspects it assumes. Out of the system of organs that are 
always affected in fever, some may be more and some may be 
less diseased ; and it is easy to see how, from this diversity alone, 
the utmost variety may arise in the external characters of the ' 
disease. Thus, at one time, the spinal cord and the brain may 



24 GENERAL DOCTRINES OF FEVER. 

be intensely affected ; consequently the patient may be seized with 
violent pains in the limbs ; with ferocious headache ; with early 
delirium, which may rapidly increase to such a degree of violence 
as to require restraint ; or, on the contrary, all the muscles of 
voluntary motion may be seized instantaneously with such a loss 
of energy that they may truly be said to be paralyzed ; at the 
same time the sensorial faculties may be overwhelmed almost as 
completely as they are in apoplexy: thus may be formed one type 
of fever : and such a concourse of symptoms is actually found to 
exist : it ushers in the plague when it first stalks into a devoted 
city to sweep away its thousands and its tens of thousands. 

At another time the disease may seize with peculiar violence 
upon the organs of secretion, and especially upon those which 
belong to the digestive apparatus: hence the liver may suddenly 
pour forth an immense flow of bile, so vitiated in quality as to 
irritate and inflame whatever it touches, and so abundant in 
quantity as rapidly to diffuse itself over every part of the body, 
and to tinge almost every tissue and every fluid : at the same time 
the stomach and intestines may be involved in such acute disease 
that the powers of life may be exhausted in a few hours by inces- 
sant vomiting and unconquerable purging : thus may be formed 
another type of fever, and such a concourse of symptoms actually 
occurs in the yellow fever of the West Indies. 

Now we may witness a severe though a less violent affection 
of the spinal cord and the brain than occurs in plague. There 
may be present great pain in the back and limbs; intense head- 
ache ; early and violent delirium ; a burning skin ; a quick and 
strong pulse ; urgent thirst, and constipated bowels ; or, on the 
contrary, there may be, not pain of the head, but giddiness ; not 
delirium, but stupor; not a burning hot, but a moderately warm 
or cool skin ; not a frequent and strong, but a frequent and feeble 
pulse. In either case we have a fair specimen of the common 
fever of our own country, the first forming the variety which may 
be termed acute, the second subacute cerebral. 

Now again we may witness a concurrence of symptoms very 
similar to the latter in the commencement of the attack, only that 
there is from the beginning greater prostration of strength ; and a 
rapid increase in the derangement of the nervous and sensorial 
functions : together with a brown and dry tongue ; a tender abdo- 
men, and dark and offensive stools ; thus may be formed another 
type of fever to which is commonly assigned the name of typhus. 

In each of these cases the most urgent symptoms have their 
seat only in one set of the organs that compose the circle which 
we have said to be involved; but in every case all the other 
organs included in that circle are as really, though not as intensely 
diseased. When the spinal cord and the brain are so violently 
affected that the patient appears to be struck with paralysis or 



DEFINITION. 25 

apoplexy, the attention is not strongly drawn to the state of the 
mucous membrane of the digestive apparatus ; to the nature of 
the secretions and excretions of which it is the source ; to the 
temperature of the system, or to the condition of the circulation ; 
because the affection of the nervous system being overwhelming, 
and all the other affections being comparatively trifling, it is na- 
tural that the former should, in a manner, absorb the mind of the 
observer ; yet, if the skin, the pulse, the tongue, the evacuations 
are examined, all will be found to be in a morbid state, and that 
morbid state will bear a certain proportion to the affection of the 
nervous system. 

In like manner when the organs of the digestive apparatus 
form the stronghold of the disease, the morbid condition of the 
spinal cord and brain, and the altered action of the heart and 
arteries, may attract less notice ; but that morbid condition will 
be not the less real, and will contribute its portion of disease to 
the general derangement of the system, not the less certainly be- 
cause the indications of its existence may be less obtrusive. 

And in the milder forms which the fever of our own country 
presents, in the most intense cerebral affection with which we 
ever meet, there will always be present unequivocal indications 
of deranged function both in the heart and arteries, and in the 
organs of secretion and excretion : while in cases in which the 
brain may be tolerably clear; in which there may be little or no 
headache ; little or no pain in the limbs ; no delirium ; in which 
the disease may be chiefly seated in the mucous membrane of 
the stomach and intestines, and the prominent symptoms be, pain 
of the epigastrium, tenderness on pressure over the whole abdo- 
men, a red tongue, and frequent stools, still if we examine the 
state of the pulse, if we look at the quality and the distribution of 
the nervous influence, if we observe the operations of the senso- 
rial faculties, we shall find these functions to be as truly, though 
not as intensely deranged as if the full force of the disease were 
spent upon the organs in which these functions have their seat. 

Thus, although all these organs are invariably affected in 
every case of fever, yet in no two cases are all these organs 
affected in the same degree. Sometimes one system is more 
affected than another ; sometimes one organ of one system, and 
these different degrees of affection, in these different systems, are 
variously combined and modified. How great, then, must neces- 
sarily be the diversity of symptoms presented by the different 
forms of fever ! How incalculable are the varieties that result 
from difference of intensity alone. One degree of affection of the 
brain, for example, will occasion violent headache, constant 
watchfulness, great restlessness, a peculiar expression of the eye, 
and intolerance of light; in another there will be no headache, or 
none of which the patient will complain ; there will be sleep, 



26 GENERAL DOCTRINES OF FEVER. 

though it be disturbed and unrefreshing ; there will be no peculiar 
expression of the eye, and no intolerance of light. By one degree 
of affection, the sensibility will be rendered preternaturally in- 
tense ; by another it will be totally obliterated ; one will produce 
violent delirium, another, only slight wandering, or unrefreshing 
slumber; one, violence requiring restraint, another, profound 
coma. In the circulating system, the symptoms will alike vary. 
One degree will produce a quick, strong, and hard pulse; another, 
a quick, small, and feeble pulse ; another, a slow and intermittent 
pulse. A similar diversity will be found in the temperature of 
the body ; in one, the heat will be little changed ; in another, it 
will be below the natural standard ; in a third, it will be intense, 
and the organs of secretion and excretion will equally vary in the 
extent of their morbid changes. 

Thus, from one and the same affection of one and the same 
organ, not only different but opposite symptoms will be produced 
in all the organs involved in what we may call the febrile circle. 
When to this variety are added diversities occasioned by various 
stages of the diseased processes that are going on in the system ; 
by the previous state of the organs affected ; by the reaction of 
the affected organs one upon another, producing innumerable and 
ever-varying combinations of different intensities of affection, in 
different sets of organs ; and by the treatment to which the whole 
have been subjected, we cannot wonder if the symptoms of fever 
appear to be countless. 

That no two cases of fever can be precisely the same, and that 
it must be vain to seek for the common phenomena of the disease 
in the external symptoms, must now be obvious ; and why suc- 
cess can never attend the search after these common phenomena 
in such symptoms as c shivering, frequent pulse, heat/ must be 
equally manifest. These, as well as all other symptoms, depend 
upon the state of the organs. But we have seen that in one de- 
gree of the same affection of the same series of organs, there may 
be shivering ; excited pulse ; burning heat ; while in another there 
may be no shivering, a slow pulse, and a cold skin ; so that from 
one and the same affection, differing only in the degree of its 
intensity, the symptoms may not only vary, but be directly oppo- 
site. The proper object of pursuit in all these inquiries, therefore, 
is the real nature of the affection, and the symptoms are of conse- 
quence only as they are indications of the existence of that affec- 
tion. Symptoms are not the thing in which observation should 
terminate, but signs of the thing, without the knowledge of which, 
in every individual case that may come under his care, the prac- 
titioner ought never to be at rest, and to the discovery of which 
they serve as guides." — (Treatise on Fever, p. 40.) 

The peculiarities by which Idiopathic Fever seems best to be 
distinguished, are thus described by Dr. Alison : — 



DEFINITION. 27 

" I. There is the negative fact, that in many of the cases to 
which this name is given, the general febrile symptoms, — the 
chilliness and lassitude, the subsequent reaction, and often long- 
continued acceleration of pulse and heat of skin, the thirst, ano- 
rexia, various uneasy sensations, and derangement of all the 
functions of the body (whether functions of the vascular or ner- 
vous system),— are unattended during great part or the whole of 
their progress by any such local symptoms, — such fixed and per- 
manent local uneasy feeling, — or such peculiar change of the 
sensible qualities — derangement of the functions of any one part 
of the body, as justifies the belief that any individual organ is 
inflamed. And if these observations be thought ambiguous, on 
account of the occasional occurrence of cases of latent inflamma- 
tion, formerly mentioned, the absence of local inflammation, in 
many such cases, is farther attested by the fact, to be afterwards 
stated, that they sometimes terminate fatally, without any satis- 
factory evidence appearing, on dissection, of inflammation of any 
part of the body 5 and very generally with so slight appearances 
of that kind, as are inadequate to the explanation of the fatal 
event. 

II. Besides this negative observation, which applies only to a 
part of the cases thus named, there is the positive observation, 
applicable probably to all cases of idiopathic fever, although 
much more obvious in regard to some than others, that the typhoid 
symptoms, formerly shortly described, (and which may always 
be held to imply the action on the system of some cause distinct 
from mere local inflammation,) are distinctly to be perceived. 
These typhoid symptoms show themselves in one or other, but 
generally in several, of the following ways : 

1. In the state of the Circulation, the pulse having very gene- 
rally, from the commencement, or early in the disease, less strength 
or resistance to compression than in the fever which usually 
accompanies simple and decided inflammation, at the same period 
after the attack. 

2. In the state of the Secretions, which are more deranged, 
and generally more diminished, than in inflammatory fever ; as is 
sufficiently obvious in the fur on the tongue, and the secretions of 
the mouth, becoming viscid, dry, and dark-coloured ; in the more 
complete failure of appetite ; and generally, after a short time, in 
the greater dryness of the surface of the body, attended in most 
cases by a more pungent, though less enduring, heat of the 
surface. 

3. In the state of the Nervous System, the greater tendency 
to stupor or confusion of thought, generally to be detected even 
in the commencement, and very obvious in most cases throughout 
most of the disease, often showing itself unequivocally in the later 



28 GENERAL DOCTRINES OF FEVER. 

stages by the involuntary voiding of the excretions which are 
naturally under the restraint of the will ; the greater weakness, 
vertigo, and faintness on attempting exertion, in the early part of 
the disease, attended generally with much tenderness of surface 
and general soreness ; the frequent tremors and subsultus ten- 
dinum, even when no exertion is made ; the greater derangement 
of the external senses, particularly of that of hearing ; the greater 
tendency to delirium, as the disease advances, and the usually 
peculiar character of that delirium, which extends to all the trains 
of thought in the mind, is unattended with propensity to violence, 
and is more or less blended with, or graduates into, stupor, and 
hence is generally designated by the epithets low, muttering. 

4. In the state of the Blood, which is probably al ways so far 
altered in its vital properties, in Idiopathic Fever, as to coagulate 
less firmly than usual, and in some cases loses the power of coagu- 
lation altogether ; in connection with which state we frequently 
observe more or less of the symptoms formerly called those of 
putrescency in fever, petechise or vibices, passive hemorrhages, 
and gangrene from slight irritation. 

5. These symptoms, and especially the indications of nervous 
affection, and of putrescent tendency, are very generally sufficient 
to distinguish idiopathic from any form of inflammatory fever ; 
but in many cases there is a farther positive distinction in the ap- 
pearance of peculiar or specific inflammations of the skin, sub- 
sequent to the attack of the fever, which take different forms, — 
essentially characterizing the fevers that are designated as erup- 
tive or exanthematous,— often appearing also in the simple con- 
tinued fever, — but never forming any part of the constitutional 
symptoms that result from local inflammation exclusively. 

III. A most important part of the history of what we call 
Idiopathic Fever, distinguishing it from the acknowledged effects 
of inflammation, is its much greater tendency to a spontaneous 
favourable termination. This is shown in different ways. In 
many cases the febrile symptoms return at regular intervals of 
24, 48, or 72 hours ; and subside completely after a cold and hot 
fit of some hours' duration, by a spontaneous sweating — consti- 
tuting the Intermitting form of fever. In others there are equally 
distinct, but less perfect and less regular remissions of the symp- 
toms, and the term applied is Remittent Fever. And in the 
remaining or Continued form of Idiopathic Fever, although we 
can observe only slight and partial abatement of the symptoms at 
different hours of the day, we very often observe complete reco- 
very from the most urgent and distressing symptoms, taking place 
spontaneously at various periods of the disease, — sometimes, in 
the fever of this country, as early as the 7th or even the 5th day; 
sometimes not until the 30th, or even the 40th day, most generally 



FORMS OF FEVER. 29 

between the 10th and 20th ; sometimes very rapidly, and with 
evacuations (whether at regular or irregular times) evidently 
resembling the sweating stage of intermittents ; sometimes gradu- 
ally, and without any such critical evacuations ; but under very 
various treatment, — often without the use of remedies, — and 
always with less assistance from remedies, and with much less 
risk of subsequent organic disease, than where recovery takes 
place from an equally disordered state of the system, consequent 
on decided internal inflammation. 

IV. There is this farther leading peculiarity in the cases of 
febrile disease, to which we give the name of Idiopathic Fevers, 
that they are often absent for a length of time, even from large 
communities, and again at other times, or in other districts, are 
extremely prevalent; and, therefore, evidently do not proceed 
merely from causes which are of general operation, as the exciting 
causes of inflammation are, but must necessarily result from 
causes of more local and temporary agency ; and accordingly, we 
have good evidence, that all these idiopathic fevers either origi- 
nate from a malaria, or propagate themselves, in part at least, 
and in certain circumstances, by contagion. 

By attention to these particulars in the history of many febrile 
disorders, even independently of attention to the results of prac- 
tice, we are authorized to conclude, that they may be distinguished 
from the effects of simple inflammation, and belong to the class 
which we call, for the present, Idiopathic Fevers ; and that the 
onus probandi rests with those who would attempt to assimilate 
them to, or resolve them into, the acknowledged effects of inflam- 
mation." — (Alison's Outlines of Pathology, Am. Ed., p. 233.)] 



II. FORMS OF FEVER. 

Fever presents itself in a very great variety of forms. The 
most precise mode, perhaps, of regarding them in connection with 
one another, is to proceed at the outset from the simplest of them, 
Ephemera, or one day's fever. 

Ephemera, so called because it seldom lasts above twenty-four 
hours, begins with chilliness or rigor, paleness, weariness, a fre- 
quent, small pulse, and indifference to food. These symptoms are 
followed in half an hour, or a little more, by heat of skin, flushed 
face, frequent, hard pulse, occasionally headache, and a peculiar 
sense of fatigue, restlessness, and slight soreness in the muscles, to 
which the name of febrile sensation, or febrile anxiety, has been 
conveniently given. When this state has continued for twelve, 
eighteen, or at most twenty-four hours, gentle perspiration breaks 
out ; under which, in the course of little more than another hour, 



30 GENERAL DOCTRINES OF FEVER. 

every essential symptom vanishes, leaving behind some exhaus- 
tion, muscular debility, and feebleness of the appetite. This 
disease, the simplest and slightest of all forms of fever, although 
on account of its shortness it seldom attracts much notice, is, 
nevertheless, not uncommon during the irregular weather of our 
spring months in Britain. 

If such an affection be supposed to recur several times every 
other day, with an interval of comparative health in the interven- 
ing days, a clear idea will be formed of Intermittent Fever 
in its most frequent and characteristic shape — the tertian type ; 
and from the tertian may be derived all the other forms of inter- 
mittent. 

If, in the next place, the febrile state be conceived to be rein- 
forced twice a-day, or oftener, by a fresh attack of rigor or chilli- 
ness, with subsequent reaction, before the pre-existing pyrexia 
has materially subsided, a distinct conception may be formed of 
Remittent Fever. 

From Remittent Fever most nosologists deduce the only remain- 
ing primary type, Continued Fever, by supposing the remis- 
sions to become gradually less and less distinct; and this view may 
seem so far conformable with nature, that almost all continued 
fevers present, more or less, a tendency to regular or irregular 
remissions^ Specially for some days at the commencement. 

But it is, perhaps, fully a clearer, and certainly a more direct 
way of deducing them, to conceive the ephemera merely pro- 
longed to such a duration, as that its several stages occupy be- 
tween four and nine or eleven days, thereby constituting, in the 
first instance, the simplest of all forms of continued fever, usually 
known by the specific name of inflammatory fever, or Synocha. 

It is probable that inflammatory fever is the fundamental type 
of all primary continued fevers. It is acknowledged that all pri- 
mary fevers, but especially those of the continued type, even in 
its simplest form of inflammatory fever, present, in comparison 
with other febrile diseases, a great degree of debility, or exhaus- 
tion of the nervous system ; which is marked among other symp- 
toms by great muscular feebleness, both during the prevalence of 
febrile action, and for some time also during convalescence. Now 
sometimes, where inflammatory fevers are disposed to run a 
longer course than usual, the symptoms of nervous depression, 
aggravated undoubtedly by the pre-existing reaction of the circu- 
lating system, come to constitute, in the latter stage, the most 
conspicuous character of the disease ; and in particular they veil 
more or less, and even sometimes overwhelm, the original cha- 
racter of pure reaction that distinguished the earlier stage, thus 
giving rise to extreme muscular depression, and disturbance of 
the powers of the mind in the shape of stupor, with or without 
delirium. Such a sequence of pathological phenomena conveys 



FORMS OF FEVER. 31 

the clearest idea of the second well-marked variety of continued 
fever in its simplest form, which is commonly known to nosogra- 
phists by the name of Synochus. At other times, again, the 
symptoms of exhaustion and disturbance, becoming still more 
prominent, show themselves at an earlier period along with the 
signs of reaction of the circulation, that is, before the close or even 
near the beginning of the first week ; and thus they constitute the 
most striking general character of the disease throughout, and in 
some cases even become excessive from the very beginning. 
Fever, in this shape, forms the Typhus of nosographists— a term, 
which of late has passed into unprofessional language, and there- 
by acquired a vague meaning, almost equivalent to the generic 
word, fever. 

The three types of Continued Fever — Synocha, Synochus and 
Typhus— are the species which were admitted by Cuilen into his 
nosological system. Since his time, some have called in question 
the existence of the first type ; others have multiplied the species. 
Many have doubted, and not a few have boldly denied, that such 
a thing as a primary fever, properly so called, is to be found in 
nature. But all that has been attempted in this particular corner 
of the theory of fevers since Dr. Cuilen wrote, has had scarce any 
other tendency than to embarrass and obscure the subject. Much 
has been done for the pathology of the various forms of fever by 
the researches of pathological anatomists ; and the knowledge 
now possessed of its secondary affections has in consequence 
acquired an extent and precision, which in his days were un- 
known, and, indeed, unattainable. But the views entertained of 
fevers in the abstract have not been rendered clearer ; and many 
dogmas have been maintained, and still receive currency, which, 
in so far as they do not seem true to nature, cannot be supposed 
likely either to advance medical theory, or to benefit medical 
practice. 

All forms of continued fever, excluding always from that term 
eruptive fevers and acute local inflammations, may be arranged 
under the three types here specified. All forms which have been 
distinguished from them by medical writers in recent times may 
be viewed, both philosophically and practically, as nothing else 
than varieties, presenting peculiar features imparted by incidental 
concomitants, yet not the less essentially belonging either to one 
of the three Cullenian types of Continued Fever, or to Remittent 
Fever. There is some difficulty in assigning its true place to one 
particular variety, which, under the name of Yellow Fever, has 
deservedly attracted great attention, on account of its frequency 
in various quarters of the world, as well as the peculiarity of its 
nosological characters. But it is in all probability nothing else 
than a remittent, possibly, however, sometimes a typhoid con- 
tinued fever, with incidental or secondary accompaniments. [Yel- 



32 GENERAL DOCTRINES OF FEVER. 

low Fever is a distinct form of Continued Fever, and consists of 
a single paroxysm, of variable duration, but never repeated. The 
evidence of Rush, Lining, Mc Arthur, Wilson, Dickson, and other 
high authorities, is conclusive on this point, as will be more fully- 
shown hereafter, when we come to treat of the disorder.] 

There is also some difficulty in assigning a true place among 
primary fevers to those disorders, which have been termed in 
modern times gastric fever, and gastro-intestinal remittent. It 
seems well ascertained that the same irritations, which will excite 
local inflammation in the stomach or intestines, attended with 
symptomatic fever, may also at times excite the febrile state inde- 
pendently of positive inflammation. This happens particularly 
in the irritable constitutions of children, but may also occur in the 
more robust habits of adults. The fevers thus arising may gene- 
rally be distinguished from the primary fevers of the continued 
type, unconnected with a local cause in the body, as well as from 
intermittents, and those commonly ranked as remittent fevers. 
But they tend in various circumstances to assume the form, 
sometimes of one, sometimes of another of these fevers ; and are 
occasionally with difficulty distinguished. In a nosological ar- 
rangement, they form the passage, as it were, between primary 
fevers and febrile inflammations; and will be so considered in this 
work. 

[Fever runs a determinate course, a paroxysm consisting of 
several stages. There is, 1st, The Formative or Precursory 
stage; 2d, That of Invasion; 3d, The period of Excitement ; 
4th, The stage of Crisis ; 5th, That of Decrement, or Decline ; 
and, 6th, That of Convalescence. 

A. The Formative, or Precursory Stage, the Latent Period, 
the Stage of Incubation of the French, the Dormant Period of 
the English writers, was accurately described by Celsus.— (De 
Med., lib. ii., cap. 2.) It would appear to be the result of the 
action of the exciting causes of fever on the animal frame. The 
earliest manifestations of the morbid impression are exhibited by 
the nervous system, and consist in general of languor and depres- 
sion, with uneasy feelings ; impairment or abolition of the natural 
appetites ; and alteration in the secretions. The duration of this 
stage varies from twenty-four hours to several weeks. Its dura- 
tion is said to be in inverse proportion to the severity and duration 
of the subsequent attack. 

The subsequent stages are thus described by Dr. Copland : 

"B. Stage of Invasion; (a) The cold stage of writers is at- 
tended by debility, lassitude, painful uneasiness, or sinking at the 
epigastrium, a sensation resembling cold running down the back, 
with formication or chills extending over the limbs and general 
surface. The pulse is constricted, small, weak, or accelerated ; 
the respiration is slow, irregular, or suspirous, and attended by 



FORMS OF FEVER. 33 

anxiety at the prascordia, and occasionally by a slight dry cough. 
On these supervene gaping, sighing, pandiculation ; a sense of 
weight, pain, or constriction in the head ; giddiness, moroseness, 
depression of spirits, and disorder of the senses ; lividity of the 
lips and nails ; pallor of the skin ; the cutis anserina,and shudder- 
in gs, rigors, or shiverings, followed by, or alternating with, irre- 
gular flushes. After the rigors cease, a sense of chilliness often 
continues for some time, although the skin has become hot. 
These symptoms present various grades and modifications in the 
different types of fever ; in some the feeling of cold is actually 
attended by reduction of the temperature, and in others the heat 
is not materially, if at all, diminished, or it is even increased. 
The former is most commonly seen in the cold stage of periodic 
fevers, the latter in the invasion of continued fevers. In all, how- 
ever, the cutaneous transpiration is altogether arrested, and the 
skin is harsh and dry. The pulmonary exhalation is also dimin- 
ished, and the breath is cold. Copious discharges of pale urine 
often take place, evidently arising out of the arrest of the exhala- 
tion from the skin and lungs. Loss of the appetites, costiveness, 
thirst, and occasionally sickness and vomiting, are likewise pre- 
sent. — (b) The duration of this period may be very short, or it 
may be for many hours alternating with slight flushes. The 
shorter and more intense it is, and the severer the rigors, the 
shorter and severer will be the consequent vascular reaction, and 
the more nearly approaching the inflammatory type ; and the 
longer its duration, the more prolonged will be the fever. The 
imperfect evolution of this stage, or its slight occurrence, particu- 
larly when it is not attended by rigors, very generally indicates 
a severe malignant or typhoid state of disease. In some of the 
most dangerous cases of fever I have seen this stage so slight as 
to be confounded with the preceding one. — (c) The pathological 
states of the first period are increased in this, particularly the 
general depression of vital endowment ; the impeded functions of 
the lungs, liver, &c; the interrupted exhalation and secretion, 
excepting the urinary secretion: and the imperfect depuration and 
arterialization of the blood. ~Bu.tr the lowered vital powers be- 
come more centralized, and the congestion of the large vessels, 
especially those of the thoracic and abdominal viscera, greater ; 
conditions which terminate themselves by inducing rigors, shiver- 
ing, vomiting, and reaction of the vascular system, with the sub- 
ordinate phenomena of the next stage. 

C. Period of Excitement. — a. Incremental excitement or 
reaction — incrementum vel augmentum morbi. — [a) This stage 
commences with the disappearance of certain of the foregoing 
signs, with the increase of those that remain, and with the super- 
vention of others. Fever, in its more literal sense, now begins, 
and manifests its specific form. The gaping, pandiculation, formi- 
3 



34 GENERAL DOCTRINES OF FEVER. 

cation, and rigors disappear, and the stricture and- collapse of 
the countenance and general surface are followed by increased 
warmth and turgescence. The chilliness, however, continues for 
a short time. Pulmonary transpiration returns in some degree ; 
respiration becomes full, frequent, and sometimes laboured, and 
the breath hot. The urine is now diminished, high-coloured, 
limpid, and clear, and its discharge is often attended by scalding. 
The muscular debility, feeling of fatigue or lassitude, the pains in 
the head, loins, and limbs, the thirst, and the anxiety at the prae- 
cordia, are all increased. The countenance becomes turgid ; the 
eyes shining, but with an expression of languor; the cheeks 
flushed,, and the cutaneous surface hot, burning, and turgescent. 
The appetites are now entirely abolished ; the tongue is loaded or 
furred, or both; the pulse is free, full, and .accelerated ; often 
strong, and vibrating in the neck ; but varies remarkably in tone 
with the particular variety of the disease. There are also a sense 
of weight, fullness, and aching of the head, with giddiness, confu- 
sion of ideas, and sometimes with mental indifference, which short 
and disturbed slumbers seem to aggravate ; a morbid suscep- 
tibility or disorder of the senses ; and occasionally moroseness, 
restlessness, or jactitation. These symptoms generally increase, 
often presenting in the continued type slight remissions in the 
morning, with exacerbations in the afternoon and evening, and 
which are most severe on alternate days ; and, during the progress 
of this stage, delirium often supervenes, especially when it reaches 
its height. — (b) The duration of incremental reaction or excite- 
ment varies with the type and form of the disease, from an hour 
or two, as in ague, to two or three days, as in continued fevers. 
It is generally shortest in the most severe and violent attacks; but 
it never extends beyond seven days. — (c) It consists pathologi- 
cally, of reaction of the vital powers, expressed chiefly in the 
vascular system, frequently with a preponderance or determina- 
tion towards particular organs, of the efforts of life to overcome 
the more immediate effects of the exciting causes, especially the 
internal congestions, and the superinduced changes in the blood. 
During this stage determination to particular organs or tex- 
tures frequently occurs, and thus the fever becomes complicated, 
or resembles idiopathic inflammation the more closely, the less 
severely the vital power and the circulating fluids are impaired or 
vitiated. Such determinations or consecutive inflammations are 
observed principally in the encephalon, spinal cord, lungs, liver, 
stomach, and bowels; they are caused chiefly by the predisposi- 
tion, previous diseases, and existing states of these viscera ; and 
by climate, season, habits, and occupations, and the circumstances 
of the individual ; whatever disorders, irritates, weakens, or causes 
habitual determination, or increased momentum of the circulation 
to either of these organs, thus complicating the fever. Hence the 



FORMS OF FEVER. 35 

cerebral complication is most common in the studious ; the gas- 
tric and hepatic, in those addicted to the pleasures of the table or 
to intemperance, and in hot climates, or during warm seasons ; 
the pulmonary, in cold countries and seasons, and in persons 
much exposed to the open air ; and the intestinal, or dysenteric; 
in the ill-fed, in persons using unwholesome water, or living upon 
innutritious and watery food, and in low and moist situations. 
The prevailing epidemic constitution has also a most powerful 
influence ; the complications, as well as the particular form and 
type of fever depending upon it, and the nature of the exciting, 
concurring, and determining causes. 

j3. Stationary reaction — stadium coctionis of the humor- 
alists— consists of the persistence of the above symptoms, with 
slight modifications, and frequently with increased affection of 
particular organs, (a) Daring its progress, restlessness continues, 
with watchfulness ; delirium is often constant, or appears for the 
first time ; nervous power is gradually and almost imperceptibly 
exhausted; the pulse generally loses tone, and becomes more 
accelerated: the tongue is deeply furred and loaded, and often, 
also, parched, and mucous sordes collect about the teeth. Respi- 
ration is quick, or moaning, and the breath is foul, heavy, offen- 
sive, sickly, and loaded with vapour, ; the urine is still scanty, 
high-coloured, and clear ; the bowels are either costive or irregular, 
and the stools morbid and offensive ; the countenance becomes 
pale, heavy, collapsed, and of a sallow or unhealthy hue, some- 
times muddy or lurid ; the eyes are suffused, watery, heavy, and 
occasionally injected; the skin continues hot, pungent, or burning, 
and it afterward either evinces a disposition to transpiration, or 
becomes damp and clammy ; or it is the seat of petechias, or of 
eruptions, which, in the exanthematous fevers, appear at an 
early part of this stage ; the prostration of muscular power is- 
increased, and is often so great that the patient cannot retain his 
position on one side, but falls into the supine posture; adipose 
matter is subsequently absorbed, and the body lives upon itself; 
and, if the patient be not delirious, he complains of severe pains, 
or of a bruised sensation, or of soreness in his limbs, back, and 
loins, with confusion, vertigo, or pain in his head. 

(b) The symptoms vary remarkably in this stage with the 
type and form the fever assumes ; with the complications above 
alluded to ; with those which may supervene during the advanced 
progress of this period; with the more latent changes in the mu- 
cous surfaces, or in parenchymatous structures ; and with various 
influences and circumstances occurring during the disease. In 
some varieties of the continued type of fever the whole of this 
period proceeds with little or no evening exacerbation, while, in 
others, exacerbations are very manifest ; but this depends much 
upon the prevailing epidemic constitution. In general, feve 



36 GENERAL DOCTRINES OF FEVER, 

caused by infection, and complicated with serious visceral disease, 
or characterized by severe affection of the fluids and soft solids, 
is strictly continued ; while that produced by terrestrial emana- 
tions assumes somewhat of the remittent form, although pre- 
senting much of the continued type. — (c) The duration of this 
state of vascular reaction is shortest in agues, in which it does not 
exceed a very few hours ; and, in continued fevers, it is brief in 
proportion to the severity of the disease. It rarely, even in the 
more protracted cases, exceeds fourteen days. — (d) The patholo- 
gical states of the early part of this stage continue, in great mea- 
sure, in this part of it; but vascular action exceeds vital power, 
which is gradually lowered; and the circulating and secreted 
fluids, and the solids themselves, become vitiated, as already 
stated, and as will be more particularly shown in the sequel. 

1). The period of Crisis. — Crisis in fevers is a sudden change 
taking place at a particular period of the disease and terminating 
it. A crisis is brought about chiefly by the efforts of nature, or, 
in other words, by the febrile action itself, inducing changes in 
the functions and organs productive of a salutary effect. Al- 
though it often takes place by the unaided efforts of life, it is fre- 
quently assisted by art, and should not, therefore, be preferred 
before art judiciously employed. The critical days are the 2d, 
3d, 4th, and 5th (quotidian period); the 7th, 9th, and 11th (the 
tertian period); the 14th, 17th, and 20th (the quartan period). 
After the 20th, crises are obscure, and seldom occur till the 27th 
or 28th. Salutary changes are observed chiefly on the above, 
unfavourable changes on the intervening days ; but death may 
happen on any day. A very cold climate or season, or either 
extreme of temperature, the impure air of a hospital, the con- 
tinued operation of the causes, the complications, great vitiation 
of the fluids and solids, an active treatment, interfere with, retard, 
or prevent crises. If the exacerbations be well marked, and vital 
energy not very much reduced, a favourable crisis may be more 
confidently expected. Crises are sometimes indecisive, or con- 
sist of several abortive attempts before the end is attained, espe- 
cially when the powers of life are much lowered. When several 
critical efforts are required, each succeeding one renders the task 
more easy for the next, until the disease is gradually subdued. 

E. Period of Decline. — Sometimes the decline is prompt and 
rapid, especially after a marked crisis ; at other times it is gradual 
and slow, particularly when only slight and imperfect crises have 
occurred, or when the disease terminates in resolution without 
any very manifest critical evacuation. In the former case, the 
decline passes quickly into convalescence ; in the latter, this stage 
is often characterized by slight exacerbations, called by some 
writers posthumous crises, which are apt to be misunderstood. 
In the fevers of this country, which frequently decline gradually, 



FORMS OF FEVER. 37 

or in the second of these modes, the symptoms indicative of vital 
disturbance generally subside in the order in which they appeared. 
Organic nervous influence and the dependent functions are the 
first to be restored ; the respiratory, secreting, and excreting actions 
become natural ; the perspiration more general, free, and, if it 
have previously been offensive, clammy, or partial, more natural 
and genial ; the tongue begins to clean on the sides and point, 
and is more moistened by the commencing return of the secretions 
poured into the mouth; coma and delirium subside, and the patient 
regains his power over the alvine excretions, if it has been lost ; 
the sensorial faculties and sleep reappear, and the latter becomes 
more refreshing; the locomotive powers are freer and more ener- 
getic, the patient being enabled to turn upon his side, the sense 
of soreness and lassitude being diminished ; the appetites and 
desires return, and the excretions are gradually re-established. 
The action of the heart, is the last to subside to its natural fre- 
quency, and generally continues long afterward to be readily 
excited by slight stimuli. The urine is abundant, and deposits 
a copious sediment ; the bowels become free, the motions con- 
sistent and feculent, and the skin gradually assumes a clear and 
healthy appearance ; but emaciation increases rapidly, or now is 
more apparent ; absorption, more especially of the less animalized 
and less highly organized parts or molecules, proceeding rapidly 
as soon as vascular reaction subsides. 

F. Convalescence. — I agree with Richter and Hildenbrand 
in considering this as a stage of fever. The propriety of this 
view is obvious, especially as regards the future health of the 
patient. It is, however, altogether distinct from the malady, inas- 
much as it does not present any of the constituent phenomena, 
which still continued to exist in the stage of decline, but merely 
those of debility consequent upon acute disease. During its early 
progress, the bulk of the body still continues to diminish, or does 
not increase until it is far advanced; all the symptoms entirely 
disappear; the appetites, desires, digestive functions, the secre- 
tions and excretions are re-established, but are apt to be dis- 
ordered, and therefore require supervision ; the cuticle and some- 
times the nails are exfoliated, and the hair falls out. Irritability 
and sensibility often are increased ; and tinnitus aurium is 
sometimes troublesome ; but these subside as health is restored. 
Relapses are apt to occur in this period, especially from premature 
exposure or indulgences, or from disorder of the digestive organs; 
but they more rarely follow when fever arises from infection, or 
from a specific contagion, though other diseases may be thereby 
occasioned. 7 '— [Diet. Pract. Med., p. 1046, Am. Ed.)] 



38 GENERAL DOCTRINES OF FEVER. 



III. LOCAL DISEASES IN FEVER. 

Fevers seldom present themselves in actual practice with the 
simple characters, which, for the sake of precision, have been 
supposed in the preceding statement. The phenomena described 
above constitute the broader features by which they may be 
grouped in genera and species, for the purpose of convenient 
classification. But in special cases each kind of fever presents 
complications, by which its essential characters may be more or 
less obscured, and which become most important objects in the 
treatment — more important, frequently, than the febrile state itself. 

These complications seem to arise from one organ or set of 
organs being disturbed in their function beyond the rest, owing 
to constitutional predispositions, or other incidental co-operating 
causes. There is scarcely any end to their multiplicity. But by 
far the most frequent and the most important of them may be 
classed under the general head of local inflammations ; and the 
greater part of the remainder under that of local irritations. Local 
inflammation confessedly, and in all probability local irritation 
also, may subsist as a primary affection, giving rise to the febrile 
state as symptomatic or secondary to the local disturbance. But 
there can be as little doubt that such local disorders may likewise 
prevail incidentally in the course of primary fevers; that, although 
occasionally absent, their presence is, on the whole, the more 
general rule. 

Local inflammation, in particular, has even appeared to some 
modern cultivators of pathology, to be so invariable an accom- 
paniment of what are called primary continued fevers, that they 
have been led to call in question the existence of any true primary 
fever, and to maintain that fever of every kind is constantly a 
symptomatic affection — a phenomenon secondary to inflammation 
in some special organ. The doctrine here alluded to, which has 
gained not a few converts in this country, and which, on the 
Continent, but especially in France, seems at the present time to 
predominate,* is of so much consequence, both as striking at the 
very root of the theory of fevers previously current, and also as 
involving practical precepts of high importance, that a necessity 
arises for considering the subject in the present place in some 
detail. And the necessity becomes not the less urgent, if it be 
true, as appears highly probable, that the doctrine in question, 

* [Such certainly is not the case at present either in Europe generally, or in 
Trance in particular. Dr. Christison has, we think, rather exaggerated the 
predominance of this doctrine in France at any time. The localization of fevers 
was always stoutly resisted by the most authoritative, if not the most nume- 
rous class of French Medical teachers.] 



NATURE OF FEVER. 39 

however spacious, and however widely disseminated, is in reality- 
untenable, being founded, like many other hallucinations in physic, 
upon narrow, though so far as it goes, correct enough observation. 



IV. NATURE OF FEVER. 

It may be well to introduce this topic with a short historical 
sketch of the principal opinions which have at different times 
been held of the nature of fever. A preliminary statement of 
these opinions can scarcely fail to have at least one good practical 
tendency. The picture thus presented to the mind, of the succes- 
sive revolutions of sentiment that have taken place as to the 
theory of fever, of the ingenious absurdities which disfigured the 
early history of medicine, and of the plausible, yet not less vi- 
sionary substitutes, which the authorities in every new era of 
medical science have devised, rather to the discomfiture of their 
predecessors than to the stability of their own credit, should teach 
due caution in adopting the still newer devices of the present day, 
even though they do seem to be based on the sober discoveries of 
a faithful system of generalization, guided by a sound pathology. 

The ancient physicians were naturally led by the more promi- 
nent and tangible phenomena of the disease, namely, the altered 
state of the several excretions, to imagine that fever essentially 
depends on a morbid state of the animal fluids. This doctrine, 
espoused at the revival of letters in the fifteenth century, acquired 
soon afterwards a more definite shape under the speculations of 
the alchymists; and fever was held to be the result of a contest 
between acid and alkali within the body. For a long time after- 
wards, the fluids or humours were almost alone looked to for an 
explanation of the phenomena of fever; and hence the followers 
of the doctrine then in vogue have usually been designated hu- 
moral pathologists, or humor alists. 

[The ancients entertained the belief that in fever there was 
contest going on in the system between it and some noxious prin- 
ciple, either generated within the body, or introduced from with- 
out, which it sought to expel. Hence, some of their writers 
deduce the term fever from the Latin verb februare, to purge or 
purify ; and esteemed it a salutary effort of nature, which should 
not be interfered with. Hippocrates, considering the increased 
temperature as the essence of "fever, founded his division of the 
varieties of the disease upon this principle, whence his causus, or 
burning fever, his leipyria, or fever with the parts externally cold 
and internally hot, and his epialus, or mild fever, with a simulta- 
neous feeling of heat and cold ; when he ascribed these different 
forms of fever to the superabundance of one or other of the four 
humours, blood, phlegm, yellow and black bile, and considered the 



40 , GENERAL DOCTRINES OF FEVER. 

disease as the result of a contest on the part of nature to expel 
the morbid humour, or to render it inert or harmless by the pro- 
cess of concoction, the mind of Galen, so many centuries after- 
wards, was so well satisfied with this hypothesis, that his power- 
ful genius contented itr^lf with the mere amplification ■ of the 
conjecture and the addition of similar conjectures of his own. 
Whence assigning the different sources by which a morbid heat, 
which he also considers as the essence of fever, may be excited 
in the body, he states < that the fevers thus produced are modi- 
fied by the prevalence or putrefaction of one or other of the four 
humours of Hippocrates ; that of the three kinds of intermittent, 
the quotidian arises from the corruption of phlegm, the tertian 
from that of the yellow, and the quartan from that of the black 
bile ; that in whatever part of the body the heat begins it ulti- 
mately extends to the heart ; that as soon as this happens the 
general commotion of the vessels commences, and that in this 
manner nature is employed in exerting her powers, endeavouring 
to assimilate the good humours to the parts which are to be nour- 
ished, and to expel the bad ; but that if at any time nature is 
unable to expel all the morbid humour, either from its thickness, 
its abundance, or its tenacity, or from some obstruction of the pas- 
sage, or from her own want of power, it will necessarily undergo 
putrefaction, if it remain long in the body, and produce the most 
fatal effects unless it be expelled by process of concoction.' And 
so many centuries after Galen wrote, Sydenham, who brought to 
the study of medicine one of the most acute, upright, and inde- 
pendent minds that ever adorned it, commences a work on fever, 
which for fidelity of observation, for graphic description, for accu- 
rate discrimination, for bold and yet cautious treatment, has been 
justly considered an almost perfect model, with the following 
extraordinary assumptions : — 

" That reason dictates that a disease is nothing else than nature's 
endeavour to thrust forth with all her might the morbific matter 
for the health of the patient ; that seeing it has pleased God, the 
Governor of all things, so to constitute human nature that it may 
be fitted to receive the various impressions that come from abroad, 
it must necessarily be subject to many diseases ; that these diseases 
proceed partly from particles of air ill agreeing with the body, 
which, having once insinuated themselves into it, are mixed with 
the blood, and affect the whole with a morbific contagion ; and 
partly from various ferments or putrefaction of humours which are 
detained in the body beyond due time, either because it was not 
able to digest them, on account of the incongruity of their quality, 
or to evacuate them on account of their bulk ; that these circum- 
stances being so nearly joined to the human essence that no man 
can clearly free himself from them, nature provided for herself 
such a method and concatenation of symptoms as that she might 



NATURE OF FEVER. 



41 



thereby expel the peccant matter, which would otherwise ruin the 
whole fabric ; that the plague, for instance, is nothing but a com- 
plication of symptoms by which nature casts out the malignant 
particles, by imposthumes in the emunctories, or by some other 
eruptions, that were drawn in by the air : that the gout is nothing 
but nature's contrivance to purify the blood of old men, and to 
purge the deep parts of the body ;/that when nature requires the 
help of a fever, whereby she may be able to separate the vitiated 
particles from the blood, or otherwise expel them, either by a 
sweat, a looseness, or some kind of eruption, she accomplishes 
this object in the whole mass of blood, and that by a violent 
motion of the parts ; that when this object is accomplished sud- 
denly, either by the health or death of the patient, the disease is 
acute ; when, on the contrary, the matter of the disease is of such 
a nature that it cannot have the assistance of a fever for the sepa- 
ration of it ; or when this kind of matter is fixed to any particu- 
lar part, which .is unable to exclude it, or when the blood is vitiated 
by the continual flow of new matter into it, in these cases, the 
matter being very slowly or not at all concocted, the diseases 
which proceed from such unconcocted matter are called chronic : 
that acute diseases proceed from a secret and inexplicable altera- 
tion of the air infecting men's bodies ; that these diseases do not 
at all depend on a peculiar crasis of the blood and humours any 
otherwise than the occult influence of the air has imprinted the 
same upon them ; that they continue as long as this secret consti- 
tution of the air, and no longer ; that they do not come at any 
other time ; and that these constitute epidemic fevers ; that on the 
other hand, acute diseases arise from this or that particular irregu- 
larity of particular bodies, which, because they are not produced 
by a general cause, do not, therefore, invade many at once ; that 
this species comes every year, and at any time of the year ; and 
that these may be called intercurrent or sporadic, because they 
happen at any time during the prevalence of epidemics."* {South- 
wood Smith's Treatise on Fever, p. 14.) 

During the seventh and eighth centuries the Arabians attributed 
fevers to a superabundance of impure or thick blood, which they 
conceived to be connected with a similar state of the bile and 
other humours. They pretended to dilute the former by purging, 
and evacuate the latter by bleeding. Avicenna introduced some 
changes into the current theory of Galen. He attributed the 
phenomena of fever more to- a superabundance of the different 
humours than to any change or degeneracy in their constitution.] 

The doctrines of Humoralism held undivided sway over the 
minds of physicians, in one shape or another, till the close of the 
seventeenth century. About this period they constituted a part 

* Sydenham's Works, p. 1, 2, &c. 



42 GENERAL DOCTRINES OF FEVER. 

of the theory of Stahl, who maintained that fever arises from 
plethora or fullness of vessels, and cacochymia or a depraved 
condition of the fluids; that it consists essentially of an effort of 
nature to get rid of these morbid states ; and that the effort is 
accomplished under the direction of a sox\\—aatocrateia, or 
governing principle within the body, which acts without any 
physical necessity, and purely through its own intelligence. [The 
idea of the influence of the archeus or vital principle in the pro- 
duction of fever originated with VanHelmont. (JDe Feb. c. xvi, 
p. 783.)] The theory of Stahl obtained wide circulation ; like 
the doctrine which it displaced, it gave rise to grave practical 
errors. The views of the alchymists engendered a vain confi- 
dence in. chemical remedies, for neutralizing or otherwise correct- 
ing the morbid condition of the fluids. The views of Stahl, by 
assuming the intervention of a free agent within the body, or an 
inherent vis medicatrix, inevitably led to an undue reliance in 
nature alone for the issue, and to the adoption of what has been 
aptly termed the medicina expectativa. So extravagant was the 
length to which his followers carried his principles in this respect, 
that some of them even established the sincerity of their creed by 
declaring their opinion that fever is a salutary operation, which 
scarcely merits the name of a disease — " ne quidem morbum 
vocari merere." 

The attempt made by Stahl to call in the aid of an intelligent 
governing principle to account for the phenomena of fever, pro- 
bably gave rise to the first decided improvement in this branch of 
pathology, which consisted in some share of influence being 
allowed to the operations of the nervous system. For this step, 
as well as for delivery from the trammels of a pure Humoralism, 
medicine is, mainly indebted to Hoffman. Hoffman maintained 
that fever consists in spasm of the capillaries, which engenders 
reaction of the circulation as the means by which the spasm is to 
be overcome ; and he referred the cause of spasm in the capilla- 
ries to some morbid affection of the nervous system. In conse- 
quence of looking chiefly to an altered state of the solids as the 
essence of fever, Hoffman and his followers have usually been 
termed Solidists. To this theory Cullen afterwards gave more 
precision, by maintaining that the first incident in the chain of 
sequences constituting fever, is a depressed state of the brain and 
nervous system; that spasm of the extreme capillaries results 
from this depression ; and that reaction of the circulation, with its 
accompanying phenomena, is an effort of the system to overcome 
the spasm. The Cullenian theory, in a modified form, continues 
still to be the prevailing creed of those who adhere to the tenets 
of Solidism, and who believe at the same time in the existence of 
primary or essential fever. 

[" Cullen, building upon the foundation laid by Hoffman, 



NATURE OF FEVER. 43 

rivaling in the number of his pupils, and exceeding in the bril- 
liancy of his success, if not in the perpetuity of his fame, any name 
of antiquity, achieved with unexampled ease and suddenness this 
great revolution; and in opposition to the ancient theories taught, 
that the first change induced in the animal system, by the opera- 
tion of the exciting causes of fever, is a diminution of the energy 
of the brain; that all the powers of the body and all the faculties 
of the mind, that the functions of sensation and motion, the pro- 
cesses of respiration, circulation, and secretion, all fail or are 
diminished in the general debility ; that after a certain time a 
morbid increase of some of these functions, especially of the cir- 
culation, takes place with an augmentation of the heat ; that these 
three states, that of debility, of cold, and of heat, bear to each 
other the relation of cause and effect ; that the first state is the 
result of the sedative or debilitating influence of contagion, marsh 
miasmata, cold, or any other exciting cause, and the subsequent 
states the result of the first ; that the debility produces all the 
phenomena of the cold stage, and especially a spasmodic constric- 
tion of the extreme arterial vessels ; that this spasm or atony of 
the extreme vessels exists not only on the first attack of the cold 
stage, but remains during the whole subsequent course of fever ; 
that the spasm of the extreme vessels throws a load of blood on 
the central parts of the circulating system, which proves a source 
of irritation to the heart and arteries, and excites them to a greater 
action ; that this increased action, the source of the heat and the 
other phenomena which constitute the second or hot stage, continues 
till the spasm is relaxed or overcome ; and that this excitement of 
spasm for the purpose of producing the subsequent reaction, is a part 
of the operation of the vis medicatrix naturze, the innate preserv- 
ing power of the constitution. « Upon the whole/ says this cele- 
brated theorist, < our doctrine of fever is explicitly this. The remote 
causes are certain sedative powers applied to the nervous system, 
which, diminishing the energy of the brain, thereby produce a de- 
bility in the whole of the functions, and particularly in the action 
of the extreme vessels. Such, however, is at the same time the 
nature of the animal economy, that this debility proves an indirect 
stimulus to the sanguiferous system ; whence, by the intervention 
of the cold stage, and spasm connected with it, the action of the 
heart and large arteries is increased, and continues so till it has 
had the effect of restoring the energy of the brain, of extending 
this energy to the extreme vessels, of restoring therefore their 
action, and thereby especially removing the spasm affecting them; 
upon the removing of which, the excretion of sweat, and other 
marks of the relaxation of excretories, take place/ "* (S. Smith's 
Treat, on Fever, <$'C, p. IS.) 

* Cullen, First Lines, S. 46. 



44 GENERAL DOCTRINES OF FEVER. 

In this system of the Edinburgh Professor, it has been remarked 
by Dr. Parr, that the production of spasm by debility is an iso- 
lated fact without a support, and the introduction of the vix medi- 
catrix nature is the interposition of a divinity in an epic when 
no probable resource is at hand.] 

Although the eminent reputation of Hoffman and of Cullen 
quickly attracted crowds of proselytes to the doctrines of Solid- 
ism, the ranks of the Humoralists were still by no means deserted. 
About the same period, Boerhaave, while adopting the princi- 
ples of Solidism for the basis of his opinions, nevertheless admitted 
also the co-operation of chemical changes of the fluids in produc- 
ing fever. Even Cullen himself allowed that, in certain circum- 
stances, the fluids underwent morbid changes; but, in accordance 
with the principles first clearly propounded in the preceding cen- 
tury by Baglivi, he held that these changes were the conse- 
quence, not the cause, of the disease. In recent times an attempt 
has been made to revive the humoral pathology by a more accu- 
rate chemical examination of the fluids, and in particular of the 
blood. The facts which have been ascertained certainly seem to 
show that a morbid state of the blood may perform an important 
part, in developing some of the phenomena of fever. But the 
discoveries thus made are very far from bearing out the conclu- 
sion which has been drawn from them by some of the cultivators 
of this line of inquiry, for example by Dr. Stevens, that fever is 
entirely and fundamentally owing to the changes in question. 

[Similar views regarding the agency of the blood in the produc- 
tion of fever have been entertained by Dr. W. Stoker, of Dublin. 
" Typhoid or adynamic fever," says he, " I consider to be generally 
symptomatic or morbid changes in the physical characters of the 
blood, and have, as on former occasions, stated" what those morbid 
changes are — but I have arranged inflammation under the head 
of symptomatic fever, merely because it is more usually connected 
with some change in the structure of parts, discoverable -after 
death ; on the other hand, typhus fever is connected with morbid 
changes that primarily take place in the fluids, and produce 
morbid actions, and sometimes permanent changes of structure in 
the said parts. These changes, too, in the condition of the blood 
are distinguishable from those which we have stated to occur in 
inflammation ; and the morbid actions excited relatively by those 
changes in the blood are also distinct. In inflammatory fever on 
the one hand, increased action, in typhoid fevers, on the other, 
debility is almost the immediate consequence. On account of this 
debility being an essential character of typhoid fevers, I denomi- 
nated them adynamic."* This opinion was also advocated by 

* Pathological Observations, &c, pp. 73, 74. 



NATURE OF FEVER. 45 

Dr. Burne. He states " that the adynamic fever has no local seat ; 
that its nature is a morbid condition of the blood, produced by 
the operation of the primary cause, the respiration of a contami- 
nated or poisoned atmosphere ; that this morbid blood, acting on 
the brain and nervous system, is of itself sufficient, in very many 
instances, to bring about the very great derangement and imper- 
fect performance of all the functions of the organic and of the ani- 
mal life ; which great derangement and imperfect performance of 
all the functions constitute the phenomena of adynamic fever."*] 
So much attention has of late been drawn to the investigations 
of Dr. Stevens, and the facts on which his theory is founded, as 
well as the practical conclusions to which it leads, are of such a 
nature, that it is entitled here to more particular notice. Accord- 
ing to his observation, confirmed by that of other practitioners in 
hot climates, the blood in the marsh-remittent of the West Indies, 
and in yellow fever, which he considers a variety of infectious 
typhus, undergoes important changes in constitution. Even for 
days or weeks before the disease breaks out, the blood, in persons 
who have been for some time exposed to the poisonous effluvia, 
is usually dark, its serum brownish or yellow, with colouring 
globules precipitated through it, and its venous tint incapable of 
being thoroughly turned to arterial red by contact with air or 
various salts. These morbid characters Dr. Stevens seems to 
suppose, though he nowhere states so categorically, are owing to 
a diminution of the saline ingredients of the blood — those ingre- 
dients which he was the first to prove, by a set of very interesting 
experiments, to be essential for a healthy process of arterialization 
in the lungs. As the disease forms and advances, this morbid 
condition of the circulating fluid increases. The salts become less 
and less abundant ; and, in consequence, the blood becomes pro- 
gressively darker, the serum more coloured, the clot looser and 
looser, like ill-made currant-jelly in consistence, and the modena 
tint of the venous blood less and less capable of becoming florid 
under exposure to air or saline solutions, till at length what is 
found in the dead body undergoes no change with either agent, 
or even with both together. These progressive changes he main- 
tains to correspond invariably with the progress of malignant 
symptoms. And, on the contrary, it is alleged, that if the morbid 
state of the blood is encountered in time by the administration of 
natural non-laxative salts, allied to those usually found in the 
blood in its healthy condition, this fluid quickly recovers its 
healthy characters, amendment speedily ensues, and the mortality 
from one of the severest scourges of man in hot climates is re- 
duced to a mere insignificant fraction. Dr. Stevens' theory, 
therefore, is, that the poisonous miasma of marsh-remittent, and 

* Practical Treatise, &c, p. 161. 



46 GENERAL DOCTRINES OF FEVER. 

the infectious effluvia of yellow fever, alter the condition of the 
blood, especially by removing its saline ingredients ; that this dis- 
eased state is the cause of such fevers ; and, more particularly, 
that its gradual increase is the occasion of all the malignant 
symptoms, and of death. But he does not confine his inferences 
to the fevers which he has practically investigated. He holds in 
general terms, that " all essential or idiopathic fevers are primarily 
produced by a diseased state of the whole circulating current." — 
{Observations on the Healthy and Diseased Properties of the 
Blood, p. 148: 1832.) 

It is impossible to enter here into the facts and arguments by 
which these views have been supported. Let it suffice, that the 
humoral pathology has thus been for the first time placed on some- 
thing like a substantial basis. Dr. Stevens' researches go to prove, 
that the fevers of the West Indies originate in a diseased state of 
the blood. Propositions so important, however, cannot be adopted 
without strong confirmation. This they have not yet received 
from his transatlantic brethren, though his book has been before 
the world upwards of six years ; and, meanwhile, they cannot but 
be viewed with distrust in Europe, when it is found, that, contrary 
to his general inference, they will not apply to fevers universally, 
but are at variance with what is observed in the typhus of Great 
Britain. For the blood in British typhus presents no marked 
disease at the beginning ; its saline matter, though it diminishes 
as the disease advances, does not decrease out of proportion to the 
other ingredients, more especially the colouring principle ; and, in 
the worst cases, to the very last, nay, even after death, the dark 
venous tint of the blood readily undergoes the usual change to 
arterial red under agitation with air, if that experiment be properly 
managed. But further, it certainly appears not a little extraordi- 
nary, that this theory should have been propounded in regard to 
the fevers of the West Indies, without actual experimental proof 
of the fundamental fact, a diminution, and disproportionately great 
diminution, of the saline materials of the blood. Nothing could 
have been easier to determine by analytic experiments ; yet there 
is not a single analysis of febrile blood in the author's whole book, 
nor is it anywhere stated that such was ever made ; and the loss 
of the salts of the blood is allowed to rest merely on inferential 
evidence or simple asseveration. 

On the whole, it may be strongly suspected, that, like many of 
his predecessors who are blamed by him for the same error, Dr. 
Stevens has mistaken effects for causes. That important changes 
occur in the blood in the course of fever was partly known before 
by vague observation of its sensible qualities, and is now fully 
substantiated by his researches, and the experimental inquiries of 
Dr. Reid Clanny. [Dr. Clanny did not regard a vitiated state of 



NATURE OF FEVER. 47 

the blood as the proximate cause of fever, but an inability of the 
system to form blood. " The proximate cause of typhus fever," 
he says, "is a cessation of chylification, and consequently of san- 
guification, during which time the lymphatics of the whole system 
act with increased vigour, and in this manner the lymph taken up 
by them from the system supplies, for the time being, the place of 
the chyle in the blood, and as long as this state continues, the pa- 
tient labours under an acute disease, heretofore called typhus fever. 
When the chylopoietic viscera resume their functions, the disease 
gradually recedes, and health is ultimately restored.""* " Chylifi- 
cation, like secretion, is a function of the brain, which, under 
peculiar circumstances, or states of the atmosphere, is impaired, 
and in severe cases is suspended altogether; hence typhus 
fever, "t] 

But the alterations which have been hitherto ascertained, have 
by no means been proved to precede the fever. They are dis- 
tinct, at least, only after the disease has prevailed for some length 
of time ; they certainly become greater and greater as it ad- 
vances; and consequently the presumption is, that they are its 
effect, and not its cause. It seems highly probable, that a care- 
ful investigation of the state of the blood and secretions, among 
the other secondary phenomena, will lead to important reforma- 
tions of opinion as to many pathological details connected with 
fever. But the attempt to base a revival of the humoral pathology 
in its full force upon late chemical discoveries is premature, to say 
the least of it. 

When the reputation of Solidism, and of the theory which refers 
fever to spasm of the capillaries was at its highest, a totally differ- 
ent doctrine was propounded by Dr. Brown, the countryman, 
and would-be rival, of Cullen. Dr. Brown supposed that all ex- 
ternal agents possess the property of simulating a power inherent 
in the animal body, which he termed excitability ; that the result 
of their action, when natural in degree, is health ; that inordinate 
excitement produces fever, by causing exhaustion of excitability, 
or what he called direct debility ; and that defective excitement 
has a similar effect, by occasioning accumulated excitability, or, 
in his language, indirect debility. Although this hypothesis pre- 
sented much of the plausibility and flightiness which are apt to 
mislead imaginative minds, it never gained over many advocates 
in Britain. In Italy, it was for some time current. But there, 
as here, it was found to lead to the pernicious practice of treating 
all fevers alike by stimulants; and the observation of the injurious 
effects of this practice in some epidemics gradually overturned the 
doctrines whence it emanated. 

* A Lecture upon Typhus Fever, by W. R. Clanny, M. D., p. 12. 
f Ibid., p. 16. 



48 GENERAL DOCTRINES OF FEVER. 

[His theory differed, however, in no essential respect from that 
of his master. " Like his predecessor," says Dr. Smith, " Brown 
attributes all fevers to debility ; and affirms that the distinctions 
which physicians have made about the differences of fever are 
without foundation ; that they are all the same, differing only in 
degree ; that the debility during the cold state is the greatest ; that 
of the hot less ; that of the sweating stage, which ends in health 
for a time, is the least of all ; hence, in a mild degree of the disease, 
as cold is the most hurtful power, its effect is gradually taken off 
by the agreeable heat of the bed or of the sun, and the strength 
thereby gradually drawn forth ; that the heart and arteries gradu- 
ally excited by the heat acquire vigour, and at last, having their 
perspiratory terminations excited by the same stimulus, the most 
hurtful symptom is thereby removed, the hot fit produced, and 
afterwards the same process carried on to the breaking out of 
sweat ; that the cause of all these diseases, from the simplest and 
mildest intermittent to the gaol fever and the plague, is the same 
with that of diseases not febrile, to wit, debility ; differing only in 
this, that it is the greatest debility compatible with life, and not 
long compatible with it." 

The Brunonian theory never became popular in the British 
schools, but prevailed to a considerable extent on the continent of 
Europe, especially in northern Italy. Razori, having visited 
Edinburgh, became an ardent admirer of Brown, and a warm 
supporter of his doctrines. Some years subsequently, a petechial 
fever having appeared at Genoa, the stimulating treatment of 
Brown was so fatal that Razori was induced to examine his 
theory more carefully ; the result was a conviction of its errors 
and inconsistencies ; and he finally abandoned it, substituting his 
own " new medical Italian doctrine," or the " doctrine of contra- 
stimulus," which attributes an opposite state of the system to 
fever from that imputed to it by Brown, and proposes a, modified 
antiphlogistic treatment. 

The views entertained, and so long taught by our distinguished 
countryman, Dr. Benjamin Rush, may not inappropriately be 
noticed here. We shall borrow the excellent analysis of them by 
the learned editor of the American edition of Dr. Copland's Dic- 
tionary. " As Dr. Rush confined the whole catalogue of diseases 
to a single class, and called the whole assemblage a unit, so also 
he reduced all fevers to one, maintaining that they differed only 
in degree, and that every form or variety of disease consists in 
irregular action, and that this irregular action, in its turn, is the 
approximate cause of every form or modification of disease. All 
the varieties of disease, according to his system, are owing to the 
difference in the state of predisposition, and in the difference in 
the force of the exciting or acting causes. 

" Rejecting that part of Brown's doctrine which teaches that 



NATURE OF FEVER. 49 

debility, carried to a certain degree, is disease, whether occasioned 
by the abstraction of natural and customary stimuli, or by their 
excessive action, exhausting or expending excitability — which, in 
the former case, Brown called direct debility, and in the latter, 
indirect debility, and which he supposed required the application 
of stimuli of very different powers to restore the deficient excite- 
ment to a healthy grade — Dr. Rush held that debility, whether 
induced by the abstraction of stimuli, or by the excess of their 
action, is the only predisposing cause of disease. In both cases 
he supposes the debility which gives the predisposition to disease, 
is occasioned either by causes that abstract the stimuli necessary 
to support the healthy action of the several functions of the body 
(and the debility from these causes he calls the debility of abstrac- 
tion), or by such preternatural or unusual stimuli as, after first 
elevating the excitement of the system above its healthy grade, 
and thereby wasting part of its strength, afterwards reduce it down 
to that state of debility which he calls the debility of action. And 
he considers the debility to be the same, whether brought on by the 
former or the latter causes ; for the effect is an increase and accu- 
mulation of excitability, or an increased disposition to motion in 
both cases, and disease, or irregular action, the necessary conse- 
quence of the action of stimuli upon the excitability thus generated 
and accumulated. To apply these views to the subject of fever; 
as in health there exists a constant and just proportion between 
the degrees of excitement and excitability, and the force of stimuli, 
so in a predisposition to fever, as well as all other diseases which 
consist in debility and undue proportion of excitability, or preter- 
natural disposition to motion, the ratio between the force of stimuli, 
excitement, and excitability is destroyed ; in consequence of which 
the stimuli act with a force .which produces irregular action, or 
in other words, fever; and when the excitability is comparatively 
more abundant in the blood-vessels than in the other portions of 
the system, which, from their being distributed in numerous and 
minute branches to every part of the surface of the body, both 
internal and external, is frequently the case, morbid, or irregular 
and convulsive motion is produced in them by the stimulating 
action of the circulating blood ; for the equilibrium of the system 
being destroyed by the sudden abstraction of excitement, in con- 
sequence of the suspension of the natural and customary stimuli, 
the blood becomes unequally distributed, and, by acting with an 
increase of quantity and force in parts not accustomed to either, 
becomes an irritant to the muscular fibres of the blood-vessels, and 
thus an exciting cause of fever. When the excitability is redun- 
dant, and the natural or customary stimuli continue to act, the 
disease exhibits symptoms which indicate too much strength or 
activity, but more predominant in that portion of the system in 
which it has become comparatively more abundant than in the 
4 



50 GENERAL DOCTRINES OF FEVER. 

other portions of the same; and when it is deficient the symptoms 
indicate too little strength and activity in the system, and particu- 
larly in that portion of it in which the excitability is comparatively 
more defective than in the other portions ; and when either the 
quantity of the excitability or the force of the stimuli is in an 
undue proportion to each other, different degrees of excitement or 
power of action are the consequence. Rush maintained, moreover, 
that all the remote or predisposing causes of fever, and all other 
diseases, are debilitating ,and all the occasional or exciting causes 
stimulating. Among the remote or predisposing causes of fever 
he enumerates cold ; the debilitating or depressing passions of fear, 
grief, &c. ; immoderate evacuations ; famine, &c. ; all of which 
induce debility, or a diminution of healthful power, by the abstrac- 
tion of customary and salutary stimuli, in consequence of which 
the excitability accumulates and becomes redundant. 

Among the causes which predispose to fever by the excessive 
or unusual application of stimuli, he mentions heat ; intemperance 
in eating or drinking ; inordinate exercise ; violent emotions ; 
marsh and human miasmata ; contagions and poisons of all kinds ; 
bruises and burns, &c: all of these he supposes to act, by their 
stimulating power only, in the production of fever, although he 
admits that fever is frequently the consequence of the debilitating 
effects of the remote causes, without the application of any ap- 
parent stimulus, the circulating blood being sufficient, in such a 
state of excitability, to stimulate the arteries, and by producing 
irregular action, cause fever. ' Reaction,' says Dr. Rush, <is 
thus induced, and in this reaction, according to its greater or less 
force and extent, consist the different degrees of fever. It is of 
an irregular or a convulsive nature. In common cases it is seated 
primarily in the blood-vessels, and particularly in the arteries. 
These pervade every part of the body. They terminate upon its 
whole surface, in which I include the lungs and alimentary canal 
as well as the skin. They are the outposts of the system, in con- 
sequence of which they are most exposed to cold, heat, intemper- 
ance, and all the other external and internal, remote, and exciting 
causes of fever, and are first roused into resistance by them.' In 
bringing about reaction of the blood-vessels, in which fever con- 
sists, Dr. Rush rejected the vis medicatrix naturx of Cullen, 
and attributed it altogether to their elastic and muscular texture, 
being < as simply mechanical as motion from impressions upon 
other kinds of matter.'* According to Rush, then, there is but 
one fever, and one exciting cause of fever, namely, stimulus. The 
phenomena of fever resolve themselves into a chain, consisting of 
the five following links : 1. Debility from action, or the abstraction 

[* Medical Inquiries and Observations. By Benj. Rush, M.D., Phila., 1809. 
4 vols.] 



NATURE OF FEVER. 51 

of stimuli. 2. An increase of their excitability. 3. Stimulating 
powers applied to them. 4. Depression. 5. Irregular action or 
convulsion; all the links being only perceptible when the fever 
comes on in a gradual manner." (Diet. Pract. Med., Am. Ed.)] 

The present century had scarcely dawned, before the senti- 
ments of physicians as to the nature of fever became so divided, 
that it is scarcely possible to say what were the prevailing princi- 
ples of any of the great medical schools of Europe. It would 
require an undue extent of space to follow here the particular 
views which have been entertained by the chief authors who 
have laboured in this branch of pathology during the last forty 
years. But it is necessary to take special notice of one doctrine, 
which forms, in various shapes, the groundwork of the principles 
maintained by a considerable proportion of pathologists for twenty- 
five years past, as well as in the present day. This is the doctrine 
already adverted to, which denies the existence of any primary or 
essential fevers, and holds them all to be merely symptomatic of 
some local disorder. The opinions referred to this head deserve 
careful attention, not less on account of the eminence of the men 
who have promulgated them, than because they are professedly 
founded, where alone sound views of the nature of diseases can be 
founded, in the investigations of pathological anatomy. 

Early in the present century Pinel, the most acute and per- 
spicuous of recent nosographists, while he advocated the doctrine 
of the essentiality of fevers, and carefully laid down the distinc- 
tions between those which are primary and those which are 
secondary to other disorders, nevertheless seems to have opened 
the door for the new theory, by assigning to each species of pri- 
mary fever, admitted into his classification, a concomitant local 
disturbance. He held that inflammatory fever is connected with 
disturbance in the general circulating system, bilious fever with 
disorder in the digestive organs, a particular form of gastric fever 
with disease in the intestinal mucous follicles, nervous fever with 
derangement of the brain and nervous system, and typhoid fever 
with depression of the general vital powers— thus obviously, in 
some measure, localizing the disease. 

Under the extended inquiries of pathological anatomists, it was 
soon ascertained that the morbid appearances to be found in fever 
are far more numerous and important than had previously been 
supposed ; and, in the experience of some inquirers, certain ap- 
pearances were found, as they conceived, to occur so invariably, 
and to correspond so uniformly with symptoms of local disturb- 
ance from an early period of the fever, that they were induced to 
consider such pathological derangements to be connected with the 
febrile state as its real cause. In this way were formed, on the 
one hand, the doctrine of Dr. Clutterbuck, published in 1807,. 
that fever is not a primary affection, but essentially a local inflam- 



52 GENERAL DOCTRINES OF FEVER. 

mation, the seat of which is in the brain ; and on the other hand, 
the theory of Broussais, announced in 1816, who, denying equally 
the primary nature of fever, maintained that its local cause is 
irritation, or inflammation, of the gastro-intestinal mucous mem- 
brane. 

[Ploucqtiet was the first, it is believed, who assumed that in- 
flammation of the brain was the source of fever. This doctrine 
was adopted by Marcus and Clutterbuck, who supported it 
with great skill and ingenuity. Clutterbuck maintained that 
fever of every kind and degree was the result of inflammation ; 
and that all general derangements of the system can be referred 
to local organic disease. "Fever," he says, "in regard to its 
effects on the system, is the most general of all diseases, and 
gives rise, during its progress, to the greatest variety of symp- 
toms. These, contemplated in the mass, present nothing but 
confusion. Like all complicated phenomena, they require to be 
subjected to strict analysis, that their order may be traced, and 
their relation to each other and to the exciting cause shown. To 
the neglect of this may be ascribed the error, as I conceive it 
to be, which has been so generally fallen into, of considering 
fever as a universal disease, or one that affects for the first time 
the whole system; no one part being supposed to suffer neces- 
sarily before the rest. Whereas, when the disease is minutely 
scrutinized, and its first appearance accurately noticed (which, 
indeed, from the slightness and consequent neglect of the first 
symptoms is rarely done) it will be found to be strictly a topical 
affection, the general disorder of the system being merely second- 
ary or symptomatic of this. 77 * "Out of fifty cases," he continues, 
" of which I noted down the symptoms with the greatest minute- 
ness at the bedside of the sick, generally once and often twice in 
the twenty-four hours, throughout the disease, I find that no two 
of them correspond in the minute points, though they all agree 
in the essential one, that is, in a manifest affection of the brain 
and its functions ; various in degree, and probably in extent, with 
numerous but accidental complications, from the affection of other 
organs."t] 

The principles of Clutterbuck have met with few adherents 
among authors, and with still fewer proportionally among prac- 
titioners. But the hypothesis of Broussais, upheld by the enthu- 
siasm and eloquence of its founder, and professing to rest on the 
irrefragable evidence of anatomical facts, quickly spread far and 
wide, especially among continental physicians. And although it 
is now confined within a much narrower range, it is still believed 
in by many, and may be truly regarded as the parent of several 

[* Observations on the Prevention and Treatment of the Epidemic Fever, by 
Henry Clutterbuck, M. D., pp. 5, 6. 
f lb., pp. 11, 12.] 



NATURE OF FEVER. 53 

other forms, in which the doctrine of non-essentialism has been 
more recently offered to the profession, and in some quarters very 
generally espoused. Broussais — and in this respect his followers 
have shown themselves his apt and faithful pupils— took a sum- 
mary view of gastro-intestinal derangement as the source of fever. 
For so long as he could find any trace of morbid alteration of 
structure in the stomach or intestines, no matter how slight or 
vague the appearances might be, he felt at no loss in ascribing 
the general disorder to a local cause. Others, however, have 
not been quite so easily satisfied. They believe that Broussais 
saw with the vision of a theorist ; that he discovered structural 
changes invisible to other unprejudiced eyes ; and that he fre- 
quently mistook, for true morbid appearances, the pseudo-morbid 
results of operations carried on in the body after death.* 

In the course of testing, however, the accuracy of his doctrine 
by the means to which it owed its origin, namely, by appealing 
to the condition of the organs of the body after death, it was 
remarked, especially in certain localities, and above all in France, 
that one particular form of fever, more frequent and more import- 
ant perhaps than any other, often presented itself in connection 
with an undoubted and formidable local disorder of the intestinal 
canal, which consists of inflammation of the solitary and conglo- 

* [Broussais' exposition of his doctrine is as follows. — " On doit regarder com- 
me necessairement affectes, dans une maladie, les tissus dont l'irritation estcon- 
stante durant la vie, et qui en offrent toujours des traces apres la mort. Or, les 
phenomenes de la sur-excitation des muqueuses, et surtout de la gastrique, ne 
manquent jamais, dans le typhus febrile, puisque leurs symptomes sont identiques 
avec ceux des gastro-enterites sporadiques ; tandis que ceux des autres phleg- 
masies ne s'y montrent qu'accidentellement. Ensuite, lorsque les personnes 
affectees de typhus ont le malheur de succomber, on trouve toujours ces mem- 
branes rouges, brunes ou noires, pendant que les autres tissus n'offrent d'altera- 
tion que dans certalnes circonstances accidentelles ; done l'irritation des mem- 
branes muqueuses est inseperable du typhus febrile. 

Les typhus febriles sont done des gastro-enterites, ordinairement compliquees 
de catarrhes pulmonaires ; ces deux phlegmasies sont le resultat d'un veritable 
empoisonnement, plus ou moins analogue a celui des champignons et des pois- 
sons gatees, et qui en a tous les caracteres. 

Le foie, principal annexe du canal digestif, est irrite secondairement, et sa se- 
cretion est plus ou moins augmentee. Plus le miasme est actif, plus cette lesion 
est marquee ***** plus la chaleur est intense, plus l'irritation du 
foie est inflammatoire (le fievre jaune). 

Le cerveau n'est inflamme primitivement que par 1'effet de certaines circon- 
stances qui ont fait predominer Taction dans son tissu ; telles sont les affections 
morales, la nostalgie, les chaleurs, etc.; mais il souffre toujours beaucoup par 
sympathie et quelquefois au point que son irritation passe au degre de la phleg- 
masie, et devient aussi grave que si elle etait primitive. — Exarnen des Doctrines 
Medicals, par F. J. V. Broussais, pp. 112 — 114. 

II n'y a de difference entre les gastrites qui sont ici depeintes et ces fievres, 
que celle qui depend du degre; car les gastrites aigues qu'on ne peut pas arreter 
arrivent toujours ou a l'ataxie ou a l'adynamie, dont les symptomes ne different 
pas de ceux du typhus. D'ailleurs, la gastrite, dont il est ici question, est deja 
pour les ontologists, une fievre ataxique. — Hisioire des Phlegmasies, par F. J. V. 
Broussais. Vol. III. p. 39.] 



54 



GENERAL DOCTRINES OF FEVER. 



merate glands of the intestinal mucous membrane, leading on to 
ulceration. The existence of this disorder was indicated so early 
as 1762 by Roederer and Wagler, of Gottingen,* in the course 
of an epidemic fever which prevailed in that city. It was again 
attentively observed 1813 by MM. Petit and Serres at Paris.t 
But its anatomical characters and exact seat were first determined 
by M. Bretonneau, of Tours, who considered it a distinct dis- 
ease, and termed it Dothinenteritis (bodi^v, a pimple, and htepov, 
intestine).:}: And the first who investigated the relations of the 
local disorder with fever was M. Louis, the eminent physician of 
the Hotel Dieu at Paris.§ M. Louis has been led by his extensive 
and minute pathological inquiries to the conclusion, in which very 
many pathologists, both among his countrymen and elsewhere, 
coincide with him, that the typhoid form at least of fever is always 
owing to inflammation of the glands of the intestinal mucous mem- 
brane ; that dothinenteritis is the necessary anatomical character 
of typhus. 

[Here are three misstatements. 1st. One of the chief objects of 
Dr. Louis' work is to prove the identity of all the species of the 
continued fevers of nosologists, with the typhoid fever of which* 
he treats. 2d. Far from asserting that typhoid fever is always 
owing to inflammation of the intestinal glands, in no instance 
does he suggest or maintain such causation. His language is 
that these lesions are "inseparable from the existence of the 
affection under consideration, and constitute its anatomical cha- 
racter" The difference between cause and anatomical charac- 
ter is wide. No pathologist who regarded the pustules of variola 
as its anatomical character, would be charged with viewing them 
as its cause. And 3d. Dr. Louis is inclined to the belief, that the 
character of the affection of the intestinal mucous membrane, is 
rather specific ; hence it is incorrect to apply the unqualified term 
inflammation to the state described by him.] 

Somewhat different from the doctrines of Broussais, as well 
as from those of Louis, yet based essentially on the tenets of the 
former physiologist, is the hypothesis of Professor Bouillaud. 
According to Bouillaud, fever is nothing else than an affection 

* [De morbo mucoso, Goettingse, 1762.] 

f [Traite de la Fievre Entero-Mesenterique observee, reconnue, et signalee 
publiquement a l'Hotel Dieu de Paris dans les annees 1811, 1812, et 1813, par 
M. A. Petit, l'un des Medecins du dit Hopital ; compose en partie par E. R. A. 
Serres, &c.] 

\ [It is strange that the paternity of the name dothinenterite, or dothinenteritis, 
as applied to typhoid fever, should have been so generally erroneously attributed 
to M. Bretonneau. M. B. styled the fever in question, dothinenterie.] 

§ [Recherches Anatomiques, Pathologiques, et Therapeutiques sur la maladie 
connue sous les noms de Fievre Typhoide, Putride, Adynamique, Ataxique, Bi- 
lieuse, Muqueuse, Gastro-enterite, Entente Folliculeuse, Dothinenterie, &c., com- 
paree avec les maladies aigues les plus ordinaires. Par P. C. A Louis, Medecin 
de l'Hotel Dieu, &c. Deuxieme Edition, Paris, 1840.] 



NATURE OF FEVER. 55 

symptomatic of irritation or general inflammation of the circu- 
lating system ; inflammatory fever, one of the degrees only of 
this irritative or inflammatory state ; and the other forms of sup- 
posed primary fever mere complications, arising sometimes from 
inflammation of the alimentary mucous membrane and its mucous 
follicles, sometimes from irritation of the cerebro-spinai system, 
and sometimes from the introduction of putrid substances into 
the blood. This strange hypothesis, much vaunted at present 
among the author's countrymen, and spoken of by himself with 
a degree of confidence which, with the exception of M. Louis, 
peculiarly characterizes the writings of the whole modern sect 
of non-essentialists, is obviously derived fundamentally from the 
hypothesis of Broussais, and engrafted with the nosological clas- 
sification of Pinel, as well as the doctrine of Frank respecting 
the origin of inflammatory fever in inflammation of the arterial 
system. 

Such are the leading opinions which have been entertained of 
late years by those who deny the existence of primary fever in 
general, or the primary nature of some of its forms. There can 
be no question that the essentialists, who look almost entirely to 
fever in the abstract, neglected too much the local affections which 
attend it, and to which so great importance has been attached by 
many in recent times. But it appears not less clear, that the non- 
essentialists have raised the importance of these local disorders 
too high, and have been led, by an excessive confidence in the 
visible indications of pathological anatomy to underrate the im- 
portance of the general febrile state. There may be a doubt 
whether all of the diseases which have been considered as fever 
by the numerous inquirers into this question, are really primary 
affections. It may in particular be doubted, whether the disorder 
described by Bretonneau and Louis is not a local disorder which 
simulates fever.* But at the same time it seems difficult for any 
one to survey dispassionately the whole facts, without coming to 
the conclusion, that fever is essentially a primary disease, and that 
most, nay, possibly all, of the local diseases which have been 
pointed out as its real source, are nothing else but secondary 
affections. From this conclusion it is doubtful whether the do- 
thinenteritis of Bretonneau may be excepted. The arguments 
by which the opinion here advanced may be supported, are chiefly 
the following: — 

In the first place, examples of the three forms of continued fever 
— synocha, synochus, and typhus — occasionally present themselves 
without any appreciable sign of local inflammation during life, or 
any corresponding appearance after death. Non-essentialists deny 

* [This supposition, gravely hazarded, can hardly be imagined from one of 
Dr.CiiRisTisoxYability. The reader will see, hereafter, innumerable and incon- 
trovertible proofs of the disorder here alluded to being an essential fever.] 



56 GENERAL DOCTRINES OF FEVER. 

this, and say that the signs and appearances in question are often 
obscure, and have merely been not well sought for. There is an 
end, however, of all argument with such controversialists. The 
symptoms and appearances of local disorder, assigned by non- 
essentialists as the cause of fever, are now well enough known to 
every scientific physician, and are frequently seen by every prac- 
tical man who turns his attention to the pathology of fever more 
especially in great hospitals. The argument advanced above is 
nevertheless still found to stand good; and the charge of wilful 
blindness may be met in the same strain by a cjiarge of wilful 
delusion of sight. Secondly, the greatest proportion of cases of 
pure fever occurs in that form of it, where local inflammation 
would naturally be expected to be most frequent, that is, in syno- 
cha. Thirdly, the greatest proportion of cases of concomitant 
local inflammation occurs in the circumstances where exposure 
to the causes of fever is most associated with exposure to the 
causes of local inflammation. Thus, instances of pure fever are 
proportionally much more frequent among the better ranks than 
among the working-classes: and that there may be no fallacy in this 
argument, from the possibility of the kind of fever being different, 
it may be added, for the sake of limiting the statement, that the 
fact is observed to hold remarkably in respect to medical pupils 
and practitioners, who take fever by infection while attending 
fever patients in hospitals and dispensaries, and where no doubt 
whatever can exist as to the identity of their diseases with that 
prevalent among people of lower condition. Thus, too, instances 
of pure fever are much more common among cases of relapse, 
than among first attacks; a circumstance quite unaccountable on 
any other principle than that local inflammation is secondary 
to fever, and arises often from simultaneous exposure to the cause 
of fever, and to the causes of inflammation. Fourthly, in a great 
proportion of instances, where local inflammation does occur in 
fever, it is secondary in point of time. It does not occur till the 
fever is fully formed ; at least signs of its presence cannot be de- 
tected for some time afterwards, and often not for a very long 
period. As a corollary from this fact it would follow, according 
to the doctrine of Essentialism, that local inflammations are least 
frequent where the fever runs a short course ; and this is actually 
found to be the case. Fifthly, where signs of local inflammation 
do show themselves, they often abate and disappear, without the 
general fever being in the slightest degree subdued, or prevented 
from running its usual course, though that may be very long. 
Sixthly, on the contrary, the symptoms usually considered essen- 
tial to primary fever may gradually disappear, and yet the local 
inflammation may continue with its peculiar signs, and come in- 
dependently to one of its customary terminations. Lastly, local 
inflammation of every sort may occur during fever; and, never- 



NATURE OF FEVER. 57 

theless, the grand features of the febrile state are essentially the 
same. We perceive the signs of chronic or of acute inflammation 
developed in one or another of almost every important internal 
organ of the body ; but still, in a genuine case of fever, no experi- 
enced physician can be at any difficulty to point out other symp- 
toms common to all, and not necessarily connected with inflam- 
mation of any organ. The conclusion seems irresistible, that there 
is something else in the disease independent of the local disorder. 
The general fact here adverted to has been the evident source of 
much embarrassment to the non-essentialists, since they cannot 
agree among themselves what is the precise local seat of the cause 
of fever, some assigning the brain as its seat, some the glands of 
the intestinal mucous membranes, some the mucous membrane 
itself of the whole gastro-intestinal canal, and some of the general 
circulating system. 

[In taking the same view — that Idiopathic Fevers are specifi- 
cally distinct from strictly inflammatory diseases, and cannot be 
ascribed to inflammatory action as their cause — Professor Alison 
holds this language : 

" I. The peculiarities of the occasional and local production, and 
application to the living body, of the exciting causes of these 
fevers, and of the characteristic depressing agency on vital action, 
which attends them, evidently assimilate, in some degree, this 
form of disease to the agency of poisons. Now, it appears from 
what was stated formerly in regard to all such poisons as act 
gradually, and must be absorbed into the system before they take 
effect, that although they may excite local inflammation, yet they 
have always a general effect, and usually a depressing effect, on 
vital action, whether of the nervous or vascular system, inde- 
pendent of that local agency. From this there arises a manifest 
presumption that the agency of malaria and of contagion, in pro- 
ducing fever, will in like manner be, in part at least, exerted on 
the system at large, and independently of local inflammation, or 
mere alteration of the distribution of the blood. 

II. Although it is admitted that appearances indicating inflam- 
mation are very frequently found after fatal fever, yet the facts 
already stated as to the morbid anatomy of fever justify our 
maintaining,^^/, That all such appearances are sometimes ab- 
sent ; secondly ', That the indications of inflammation, found in the 
different parts above enumerated after fever, are very generally 
somewhat different from those which are found after inflammations 
of the same parts excited simply by cold, and unconnected with 
the peculiar symptoms of fever; which implies the action, in cases 
of fever, of a peculiar cause, distinct from inflammation ; and, 
thirdly, That the appearances of inflammation, found after fever, 



58 GENERAL DOCTRINES OF FEVER. 

are very often quite inadequate to explain the fatal event, on the 
principles formerly stated as to the fatal terminations of inflam- 
matory diseases. 

It is plain that, in order to prove that fever depends essentially 
on, and is fatal by reason of, the attendant inflammation, it is 
necessary to show, not only that such attendant inflammation 
exists, but that its nature and situation are such as to obstruct some 
function necessary to life, — or at least such as are found, in other 
cases, incompatible with life. If, therefore, we find, after fatal 
fever (characterized by. typhoid symptoms), marks of inflamma- 
tion in certan organs, but these in a degree much less than those 
which we are accustomed to find, where the same parts have 
been inflamed, but the characteristic typhoid symptoms have not 
shown themselves, we are not entitled to infer that the inflamma- 
tion in the former case was the cause of death. 

Now, the effects and indications of inflammation, found after 
fatal fevers, and already described, are generally much less than 
what we are accustomed to observe in those cases of inflammation 
of the same parts which are unconnected with malaria or conta- 
gion, and unattended with typhoid symptoms ; and frequently all 
that is seen indicates only congestion of blood, which can hardly 
be held to be a sufficient cause for death, if existing alone, any- 
where but in the brain, or at the origins of the nerves. 

Even, therefore, where the evidence of inflammation, or irregu- 
lar distribution of blood, having existed during fever, is held to 
be decisive, the proof of these having existed to a degree which 
can be reasonably considered adequate to the explanation of the 
fatal event, is very often essentially defective. 

III. Not only the fatal event, but the chief peculiarities of the 
symptoms, of the diseases described under the name of Idiopathic 
Fevers, are very often inadequately explained by reference to any 
of the known phenomena and effects of inflammation. 

The different authors who ascribe fevers to inflammation as 
their cause, are not agreed as to the organ in which that inflam- 
mation must reside ; which circumstance is of itself a presumption 
against their common doctrine. But there is no locality which 
can be assigned to the inflammation attending fever, which can 
explain, by reference to the known effects of inflammation in other 
cases, many of the typhoid symptoms of fever. 

The preternaturally fluid state of the blood, which is very often, 
although, perhaps, not uniformly observed, certainly cannot be 
explained thus. The enfeebled state of the circulation in typhoid 
fever has been thought by some to be sufficiently explained by the 
known sedative effect of inflammation of the intestines on the 
heart's actions ; but, besides that, there are many cases of truly 
adynamic fever, where no distinct traces of intestinal inflammation 



NATURE OF FEVER. 59 

can be detected, the two cases are very different ; — the depressed 
state of the circulation in cases of simply inflamed intestines being 
preceded by much more decided local symptoms than we see in 
fever, and being neither attended with the cutaneous heat of fever, 
nor with the eruption, nor with the foul dry tongue and lips of 
fever, nor with the nervous symptoms of fever, nor with the strong 
salutary tendency of fever. And although some of the symptoms 
produced by inflammation of the brain resemble the nervous 
symptoms of many cases of fever, yet in simply inflammatory 
cases, there are more sudden and violent attacks of pain, — there 
are very generally sickness and vomiting — there is at one period 
of the disease slowness or irregularity of pulse, — the delirium is of 
a different character, — there is less stupor in the early stages, and 
the stupor in the latter stages is attended much more generally 
with dilated pupil, squint, blindness or double vision, and is much 
more uniformly fatal than in the fevers described as idiopathic. 

Farther, the appearances indicating inflammation, which are 
found after death by fever, are in many cases observed to corre- 
spond, not to any of the symptoms of the earlier periods of the 
fever, but to symptoms which presented themselves only recently 
before death; so that the period of accession, as well as the nature 
and degree of the inflammation, that can be ascertained to exist 
during the fever, is inconsistent with the supposition of all the 
symptoms depending upon it. 

In farther proof that the characteristic symptoms of fever are 
not explained by the inflammations which may accompany it, we 
should observe, that there are various cases, formerly noticed, be- 
sides that now in question, in which inflammation is attended 
with typhoid fever ; e.g., the case of inflammation from an injury 
attended with violent concussion, the case of inflammation and 
purulent effusion in a vein, the case of inflammation from a poi- 
soned wound, or from epidemic erysipelas, or other exanthematous 
disease, or puerperal fever ; and in every one of these it is obvious 
that the system is subjected to the influence, not only of a local 
inflammation, but also of a cause acting generally on the body, 
as we suppose the poison of what we call Idiopathic Fever to do. 

And if the local inflammation, which can be ascertained to take 
place during fever, is inadequate to explain the characteristic ty- 
phoid symptoms, it is equally in vain to seek an explanation of 
these symptoms, as some have done, in the mere circumstances of 
irregular distribution and congestion of blood. 

Even the peculiarities of that form of fever which has been 
described under the name of Congestive, are not to be explained 
by the mere circumstance of internal congestion, the existence of 
which, in the vessels, and especially in the veins of internal parts, 
in these circumstances, is admitted. For although congestion or 
stagnation of blood within the cranium may be held to be a suffi- 



60 GENERAL DOCTRINES OF FEVER. 

cient cause of stupor, yet we are so far from regarding conges- 
tion in the great veins leading to the heart as a sufficient cause 
for deficient action there, and consequent feeble pulse and cold 
skin, that we have already stated the accumulation of blood in 
the great veins to be apparently the chief cause of the increased 
action of the heart, or the reaction, in the more usual form of 
fever. In the cases, therefore, where the congestion in the great 
veins fails to excite this reaction in the heart, some peculiar cause 
must have operated to prevent the heart from being usually ex- 
cited, by the application of the unusual quantity of its natural sti- 
mulus; i. e., the circumstance of unusually great and permanent 
congestion in the great veins, in the commencement of fever, is in 
all probability the effect, not the cause, of a peculiar sedative in- 
fluence affecting the vascular system in these cases ; such an influ- 
ence naturally leading to accumulation of blood in the great veins, 
for the same reason that determines the accumulation there after 
death. 

That congestion of blood in the great veins is not per se ade- 
quate to account for the phenomena of any form of fever, appears 
distinctly from the fact, that no form of fever follows the great 
congestion there in cases of suspended animation in syncope, or 
from extreme cold, or submersion in water. 

IV. That what we called Idiopathic Fever cannot justly be re- 
garded as the effect of the inflammations often attending it, appears 
farther from a very sufficient experience of the juvantia and los- 
dentia, particularly from what is well ascertained of the effect of 
evacuations on the one hand, and of stimulating remedies on the 
other, in this disease, as compared with the diseases that are 
acknowledged to be simply inflammatory. For after making 
allowance for the sources of fallacy necessarily attending such 
observations, we may assert that experience has fully established 
the following points. 

1. That in the strictly inflammatory diseases, evacuations of 
blood are of the utmost use in the early stages, all other remedies 
comparatively inefficient, and stimulant remedies decidedly hurtful 
in all but the latest stage. 

2. That in the cases described as idiopathic fever, even although 
symptoms of local inflammation be present, the amount of evacu- 
ation which it is safe to practice on account of these is much less 
than, in the former case ; that its beneficial effect is less decided, — 
the local symptoms being seldom so effectually subdued, and the 
general, especially the typhoid symptoms, being seldom improved, 
and sometimes evidently aggravated by loss of blood; that the 
tendency to a spontaneous favourable termination is much stronger; 
and that even when indications of recent local inflammation exist, 
decided benefit may often be obtained from the use of stimulants, 



NATURE OF FEVER. 61 

under which the pulse may improve, and the typhoid symptoms 
of general fever abate, without the local affection being materially 
or even perceptibly aggravated. 

It is also ascertained by sufficient experience, that the inflam- 
matory symptoms are more urgent, and evacuations in general 
much better borne in some epidemics of continued fever; and that 
in others the indications of debility of the vascular system are 
more permanent, and stimulants more generally useful ; while 
no such differences are observed as to the strictly inflammatory 
diseases in different seasons. 

These statements seem sufficient to show, that it is a limited 
and hasty view of the phenomena and history of Fevers, which 
has suggested the opinion of their being resolvable into the con- 
stitutional effects of the Inflammations, or local determinations 
and congestion of blood, which can be ascertained to attend them; 
and that we may now safely apply the term Idiopathic as ex- 
pressing the belief of an essential distinction existing between 
these fevers, and those that were formerly described as resulting 
from local inflammation. 

At the same time, the strong similarity or coincidence, in many 
respects, of the essential symptoms of the symptomatic and the 
idiopathic fever, must always be regarded as a leading fact in 
reference to the pathology of the latter." [Outlines, &c.) 

Another evidence of the want of identity between fever and 
inflammation is the peculiar state of the blood often, though, 
perhaps, not uniformly observed in fever; and which is directly 
opposite to that invariably present in genuine inflammation. 
In every inflammation there is a relative increase of the fibrin 
over the red globules. According to Andral, the fibrin of the 
blood in fever, uncomplicated with acute inflammation, is never 
increased ; it remains at the physiological standard, or decreases;* 
and this to a degree never met with in any other acute disease. 

* [A frequent coincidence in fever is the diminution of the fibrin of the blood, 
and the facility with which congestion (so often confounded with genuine in- 
flammation) is produced. The circulating mass being deprived of its ordinary- 
quantity of fibrin, the red corpuscles seem to lose at the same time the power of 
regulating their movements, andaccumulate and stagnate in the capillaries. There 
is a peculiar congestion, which according to Andral is invariably connected with 
the typhoid state, whatever the disease may be. Its seat is the spleen, which 
becomes remarkable both from the increase in its volume, and the diminished 
consistence of the matter which fills its cells. Softening of the spleen in such 
cases is not due to any alteration of the tissue itself, for when by washing, the 
organ is emptied of fluid, it is found natural. It is the contained matter which 
has lost its consistence, and this is coagulated blood, retained in the areolar 
tissue of the spleen. Like all blood poor in fibrin its coagulation is imperfect. 
The same condition of the blood in similar states is found in the clots in the heart 
and great vessels. Hence the enlargement and softening of the spleen which ac- 
company all well-marked typhoid symptoms, may be considered as the effects of 
the diminution of the fibrin of the blood.— (Hematologic Pathologique, p. 71, 1843.)] 



62 GENERAL DOCTRINES OF FEVER. 

The alteration in the intestinal glands, (a common complication, 
or frequent accompaniment of continued fever,) and the eruptions 
in the exanthemata, have no effect in increasing the proportion of 
fibrin. Every form and variety of fever, in every degree of in- 
tensity, will arise with every possible proportion in the globules. 
The blood is never buffed in simple fever, in continued fever, 
variola, scarlatina, or rubeola ( Andral). The specific cause which 
produces fever, acts upon the blood in such a manner, as to tend 
to destroy the coagulable principle.] 

The statements of fact here made are consonant, it is appre- 
hended, with the experience of every British physician, who has 
been practically conversant with the phenomena of continued fever, 
as they have been presented on the great scale in the hospitals of 
this country during the last twenty years, since the appearance of 
the great epidemic of 1817. At all events, nothing has been 
stated above which has not been verified again and again, during 
that period, throughout the repeated epidemics which have pre- 
vailed in Edinburgh. The epidemics of fever, which have occurred 
in that city during the interval in question, have presented a very 
great variety of type or constitution, having gradually varied from 
the inflammatory form which characterized the earliest epidemic, 
to the typhoid character which is at present (1838) dominant. 
The opportunities of observation may, therefore, be safely said to 
have been peculiarly favourable. The facts are as already given. 
The result, it may be added, has been, that not a single observer, 
who has enjoyed these opportunities throughout, is to be found in 
the ranks of the non-essentialists. It may be granted, that truth 
is not to be put down by authority, however consentaneous. Yet, 
nevertheless, a circumstance of this kind is not without its weight 
in the argument, more especially when it contrasts singularly 
with the result as to medical opinion in other great cities, such as 
Paris, where physicians have plainly formed their conclusions 
regarding the nature of fever in the abstract from observing the 
characters of a single form rarely presented in the epidemic 
shape. 

[This assertion is erroneous. The description of Roederer 
and Wagler was founded on an epidemic at Gottingen ; that of 
Cruveilhier was drawn from epidemics at Paris in 1814, 1815, 
and at Limoges in 1816 and 1817. In all the epidemics in the 
French provinces, the special intestinal lesion was observed ; also 
at Geneva • and in numerous epidemics throughout the European 
continent; to say nothing of those in Great Britain and Ireland, 
as will be shown hereafter.] 

The arguments thus adduced against the supposed dependence 
of fever on local disorders at large are equally applicable to each 
particular disorder, which has of late been pointed out by patho- 
logists as its cause. They may be applied, for example, to the 



NATURE OF FEVER. 63 

dolhinenteritis of Bretonneau, the only cause, according to M. 
Louis and many others, of true typhoid fever [see p. 54], This 
local affection, though comparatively rare in Edinburgh, is well 
enough known to every practitioner of experience as an occasional 
accompaniment of typhoid fever, especially in times when there 
is an epidemic tendency to diarrhoea and dysentery. It has been 
recognized, by the same symptoms during life, and ascertained 
by the identical appearances after death, which have deservedly 
attracted so much attention in the French capital. But it has 
proved invariably secondary in point of date : its appearance and 
disappearance in special cases have repeatedly been observed to 
exert no influence on the essential features of the general febrile 
state : it has been occasionally seen to continue, with its proper 
local signs, long after the general fever had come substantially to 
an end, sometimes in that case undergoing a cure like the fever 
before it, sometimes, on the contrary, proving fatal ; it has been 
met with precisely in the circumstances in which cases of appa- 
rently pure fever were at the same time engendered, that is, in 
families suffering generally from typhus without any intestinal 
disease ; in cases where, judging from the symptoms and morbid 
appearances, it was entirely wanting, which cases have uniformly 
formed an overwhelming majority, the general fever has been 
precisely of the same character, and very often precisely the same 
in degree, as where the local disorder was present : and, in con- 
clusion, the intestinal disease has repeatedly presented itself in 
groups;— the constitutio dothinenterica, to speak in nosogra- 
phical language, has repeatedly appeared and disappeared as a 
subordinate or intercurrent epidemic in the course of the more 
general epidemic, typhus, without the great features of that 
epidemic being altered in any material respect. 

[The current opinions in some portions of Europe, especially 
Germany, as taught by J. P. Frank and Hildenbrand, are thus 
described by Dr. Copland. Frank " confesses that he despairs 
of conveying any exact idea, or even of coming to any satisfactory 
conclusion, respecting the proximate cause of fever. He thinks, 
however, that fever may be viewed as resulting from irritation 
induced by an unaccustomed stimulus; the powers of life reacting 
or making efforts at reaction, in order to remove it. Hildenbrand 
states nearly the same proposition in different words, in concluding 
that the cause of fever is to be found in a morbidly increased reac- 
tion of the vital forces, owing to the irritation of a morbific stimu- 
lus. He farther remarks, 1st. That all fevers are caused by an 
absolute or relative irritation, and, consequently, that they are all 
at their commencement irritative ; 2dly. That the reaction of 
fever never follows mere debility, although it is attended by 
debility ; and that the debility of the vital powers is always 
secondary, and the effect of the morbid irritation, or adventitious, 



64 GENERAL DOCTRINES OF FEVER. 

as in the progress of the disease. Admitting that it is difficult to 
explain— although I think it quite possible— how reaction of the 
vital forces can take place in the system in consequence of a cause 
primarily producing debility, more especially in the part where 
the impression is primarily made ; still it is evident that all the 
causes of fever are not positive stimuli or irritants in their primary 
action, and, consequently, that their immediate effects on the 
surface to which they are applied are not exciting. Indeed, we 
have no evidence that the effects which are proximately conse- 
quent upon their application, are similar to those which uniformly 
result from those stimuli with the action of which we are ac- 
quainted. Stimulating effects undoubtedly follow remotely in a 
majority of instances ; but they supervene in consequence of in- 
termediate operations taking place in the system itself. 

The opinions of Dr. Jackson are not materially different from 
those of Hildenbrand. He considers the material cause of fever 
to be of an irritative kind ; that it enters the body by the absorb- 
ents of the first passages, proceeding into the circulation ; and that 
it produces the febrile act by irritating the extreme series of 
organic capillaries, thereby occasioning subversion of the existing 
mode of action, and giving rise to changed or unnatural forms of 
action, through which the different secretions and functions are 
diminished, increased, or modified, in various ways and degrees."] 

The errors of pathologists in investigating the question of the 
primary or secondary nature of fever seem to have mainly arisen 
from a circumstance, to which several other important errors that 
have lately gained currency are equally owing, namely, from 
limited observation, extensive enough perhaps in one sense, but 
limited in so far as it comprised experience of the phenomena of 
the disease in one locality only, and often, too, in one epidemic of 
that locality. 

The fate of preceding theorists holds out small encouragement 
to any author of the present day to embody his own views of the 
general doctrine of fever. But some statement of the kind is 
nevertheless necessary for imparting a thorough idea of the spirit 
in which he communicates details, because no man perhaps ever 
wrote or practised in fever, without being more or less guided by 
one doctrine or another. The theory of fever, then, which seems 
most consonant with the whole facts, with the general sentiments 
of the Profession, especially in Britain, and with a sound and 
prudent practice, is probably the following. 

Fever is an essential or primary disease. [It is, in the language 
of Fordyce, " a disease which affects the whole system ; it affects 
the head, the trunk of the body, and the extremities ; it affects 
the circulation, the absorption, and the nervous system ; it affects 
the skin, muscular fibres, and the membranes ; it affects the body, 
and affects likewise the mind. It is therefore a disease of the 



NATURE OF FEVER. 65 

whole system, in every kind of sense. It does not, however, affect 
the various parts of the system uniformly and equally, but on the 
contrary, sometimes one part is much more affected, compared 
with the affection of another part. Sometimes those parts which 
Avere most affected at one time, are least affected at other times, 
so that the appearances which are the principal ones in one fever, 
are by much the slightest in another, or sometimes are totally 
absent." (Fordyce on Fever, p. 16, 2d Am. ed. 1823.)] The 
first appreciable event in the chain of sequences constituting fever 
is a functional injury of the nervous system. The only essential 
or invariable consequence of this affection is functional derange- 
ment of most of the important organs of the body, but more 
especially of the brain, the circulating organs and fluid, the ali- 
mentary canal, and the skin. The characters of fever vary in 
some measure from year to year, and in different places, owing to 
unknown causes, which, for convenience, have been included 
under the generic term " epidemic constitution." The variations 
in its character, constituting varieties of primary type, probably 
depend on differences in degree in the primary functional derange- 
ment of the nervous system. Other variations, consisting in the 
undue development of special local disorders, whether functional 
merely, or passing into the organic character, or truly organic, 
depend partly on epidemic constitution, partly on manifest con- 
curring causes acting at the moment of invasion of fever, or in its 
course. The changes which have hitherto been observed to 
take place in the blood and other animal fluids, are, like the local 
disorders, secondary and not primary : they may be the source of 
the phenomena remarked in the advanced stage of the disease, 
but they are not the source of the disease itself in the first in- 
stance. The preceding principles are, in correct philosophical 
language, matters of theory, capable of being decided by facts so 
soon as pathologists are agreed respecting the facts. If we wish 
to advance a step further, and tread in the regions of hypothesis, 
then it seems a reasonable doctrine, that the primary disturbance 
of the functions of the nervous system acts first on the capillaries 
or extreme vessels of the surface, as well as throughout the in- 
ternal organs, and produces, not spasm, as was imagined by 
Hoffman and Cullen, but rather, according to modern views of 
the state of the capillaries in inflammation, a state of atony, relaxa- 
tion, and distension, and consequently obstruction to the passage 
of the blood ; that the disturbed state of the circulation is an effort 
excited by the stimulus of this obstruction for accomplishing its 
own removal; and that the disturbance of the function of circula- 
tion is variously modified by the constant co-existence and direct 
influence of the disturbance of the nervous functions. At all 
events there seems no question, that there are always two leading 
phenomena in fever, howsoever induced — disturbance of the nerv- 
5 



66 GENERAL DOCTRINES OF FEVER. 

ous system and disturbance of the circulation : that, howsoever 
connected originally in the chain of sequences, they act and react 
on one another ; and that their co-existence and reciprocal action, 
while they account on the one hand for many subordinate phe- 
nomena which are otherwise unintelligible, must on the other be 
kept constantly in view as modifying singularly the effects of 
remedies, and therefore regulating, in many essential respects, the 
method of cure. 

[With regard to the morbific cause which produces and main- 
tains the peculiar characters of febrile phenomena, some important 
points are to be considered. Having elsewhere* expressed our 
concurrence in the pathological views of Professor Alison on this 
subject, we shall transfer them to these pages : 

" I. It may be questioned whether the effect on the Nervous 
System, essential to fever, is produced directly by the external 
cause of fever, or whether that cause first works a change on the 
blood, and through its intervention affects the brain and nerves. 

It is plain that the blood is changed, at least as to its power of 
coagulation, in most cases, and probably it may be so in all cases 
of idiopathic fever. But a similar change as to that property may 
be produced in it, by causes acting in the first instance on the 
Nervous System ; and this fact, therefore, does not indicate the 
part of the system which is primarily affected in fever. 

Reasons which appear, on first consideration of the subject, 
satisfactory, may be given against the supposition of many of the 
older pathologists, that fever essentially and exclusively consists 
in a certain change in the blood, (quae prassens morbum facit, 
sublata tollit, mutata mutat); in particular, two facts already 
stated, viz. 1. That after the morbific cause has been applied to 
the blood, it may depend, as we believe, on causes acting on the 
Nervous System only, whether or not it shall produce its specific 
effect ; and, 2. That even after that specific effect has been pro- 
duced, and the febrile actions begun, they may, in a few instances, 
be arrested by means (such as the cold affusion) which neither 
evacuate any part of the blood, nor alter its composition. But 
when it is distinctly understood that the change in the blood, 
believed to be morbific, is not in its chemical constitution simply, 
but in the vital qualities by which that constitution is constantly 
regulated and maintained, these facts have not the weight against 
the humoral pathology of fever, which has been ascribed to 
them. 

At least it may be thought, that the remote cause of fever does 
not produce its effect by merely once impressing the Nervous 
System, or other living solids ; but that it must necessarily affect 

* [Williams' Principles of Medicine, Am. Ed., p. 283.] 



NATURE OF FEVER. 



67 



for a time the fluids of the body, and perhaps multiply itself in 
them, in order that it may take effect on the solids. And in favour 
of this form of the humoral pathology of fever, the following 
facts may be stated : 

1. In a great majority of the cases in which we see typhoid 
fever, we are sure that some peculiar matter, generally absorbed 
from without, must be contained in the blood ; as in the case of 
fever from malaria, from contagion, (whether of simple fever or 
the eruptive fevers,) from inflamed veins, from animal poisons 
introduced by wounds, or from suppression of the natural excre- 
tion at the kidneys. That this peculiar matter, or the blood altered 
by it, should act like a ferment, assimilating much of the circulating 
fluid to itself, in the former case equally as in the latter, is quite 
in accordance with what has been observed, when purulent matter 
has begun to form in the blood. (See Gulliver's Translation of 
Gerber,^. 104.) 

2. In all cases of idiopathic fever, as well as of the eruptive 
fevers, an interval, which is variable and often long, necessarily 
elapses between the application of the morbific cause, and the 
development of the fever; which is easily understood on the sup- 
position that a change is gradually wrought on the blood during 
that interval, but not on the supposition of the poison acting sim- 
ply on the living solids. 

3. In a great majority of cases of typhoid fever, we know 
that a matter, similar in its effects on the human system to that 
which excited the disease, is ultimately evolved in large quantity 
from the blood, making the disease contagious ; i. e., the morbific 
poison in one way or another is multiplied in the blood of the 
living body. 

It has been naturally supposed by pathologists at different 
times, that the frequent and rapid abatement of fevers after critical 
evacuations, is farther proof of the doctrine of their cause residing 
chiefly in the blood ; and that this morbific cause is really carried 
off by these evacuations. And in support of this opinion, it has 
been stated, that when putrid matters, or diseased secretions, 
have been injected into the veins of animals, and excited febrile 
symptoms, a peculiarly fetid diarrhoea has preceded the recovery 
from these. 

But when it is considered, 1. That copious or spontaneous 
evacuations (e. g\, of sweat) at the critical periods of fevers, often 
take place without the least good effect, if unattended by other 
marks of restoration of the natural condition of the capillaries; 
2. That many fevers abate spontaneously and perfectly without 
crisis ; 3. That in all contagious diseases, morbific effluvia escape 
for a long time from the body, without any good effect ; 4. That 
there is no evidence of the critical evacuations possessing more 
contagious property than the effluvia which continually escape 



68 GENERAL DOCTRINES OF FEVER. 

without advantage ; and lastly, that in small-pox in particular, 
experience has shown, that the morbific matter in the pustules 
may be evacuated as quickly as it appears, without benefit, and 
maybe reabsorbed into the blood without injury— we must think 
it doubtful whether the critical evacuations are the cause of the 
solution of the fever that succeeds them, or whether we ought not 
rather to regard them as the sign of the restoration of the natural 
state of the vital actions in the capillaries of the body ; whereby 
the excited action of the heart is enabled to throw off an unusual 
quantity of secretions and excretions, and then subsides ; because 
the cause confining the circulation, and therefore stimulating the 
heart, has ceased to operate. 

The doctrine of the existence of a morbific matter in the blood, 
therefore, is not established by the facts as to the critical evacua- 
tions, but must be rested on the other facts above stated. 

II. Whether the morbific cause first alters the fluids or not, it is 
evident that it affects the actions of all the living solids, whenever 
it excites fever ; and it may be questioned whether the first effect 
of the morbific cause is exerted on the living action of the nervous 
or of the vascular system. Besides what was formerly said on 
this point in treating of symptomatic fever, the following reasons 
may be given for thinking that the nervous system is much con- 
cerned in the changes occurring even from the commencement of 
fever. 

1. The nervous system is evidently more affected throughout 
the whole series of morbid actions, than in the former case, and 
the first symptoms by which the idiopathic fever can in general 
be recognized, are strictly affections of the nervous system. 

2. We have seen that when inflammation co-exists in the 
living body, with the effect of a violent concussion of the brain 
and nerves, the fever that it excites has often quite the typhoid 
character. 

3. We have good reason to believe, that changes taking place 
unquestionably in the nervous system, viz., those which attend 
mental emotions of sufficient duration and intensity, if they have 
not power (as it may reasonably be conjectured that, in certain 
circumstances, they have) to generate fever, have at least such an 
influence on its causes, as to determine their efficiency or inefficacy 
in individual cases ; which is of itself a strong presumption in 
favour of the belief, that the primary action of these causes is on 
the nervous system. 

4. Besides these mental emotions, there are various other 
agents, formerly noticed as concurrent and accessory causes of 
fever, and by which we have reason to think, that the develop- 
ment of fever, after the poison has been imbibed, is often deter- 
mined— e. g. y cold, muscular exertion, and intoxicating liquors; 



NATURE OF FEVER. 69 

and the chief action of all these causes also is on the nervous 
system. 

5. There is at least one remedy of peculiar efficacy in counter- 
acting the agency of one of the causes of fever, i. e., the cinchona, 
which produces no visible effect on the vascular system, and the 
chief action of which, there is reason to believe, from what we 
see of it in other cases, to be on the nervous system. 

But whatever be the mode in which the morbific cause, in 
idiopathic fever, comes to affect the circulation, it is to the direct 
action of this cause, and not to the influence of any local diseased 
actions excited in the body, that we must ascribe the enfeebled 
state of the circulation — the altered state of the blood— the pecu- 
liarly vitiated state of the secretions— and, in a great measure 
also, the deranged state of the nervous system — which were 
described as characteristic of idiopathic, and especially of typhoid 
fever. 

And there is nothing inconsistent with what is known of the 
action of poisons, or of other agents on the animal economy, in 
supposing that the morbific cause, after existing some time, and 
perhaps multiplying itself, in the fluids, may act simultaneously 
on the constitution of the blood, on the vital affinities in the capil- 
lary vessels, on the powers of the heart, and the vital actions of 
the brain and nerves. Indeed, if its first action be on the vital 
affinities, as formerly defined, it must necessarily affect nearly 
simultaneously all these parts. 

We have good reason to think, that it is especially by its action 
(whether direct or indirect) on the vital changes in the capillary 
vessels, that this cause excites the symptoms which were described 
as characteristic of fever ; and we refer to the account given of 
fever symptomatic of inflammation, for the explanation of the 
manner in which the different steps in the series of changes con- 
stituting febrile action, consequent on that deficient vital action in 
the capillaries, are connected together. 

But the peculiar depressing action of the morbific cause on all 
the parts of the system above mentioned, appears, from what has 
been said, to be perceptible throughout idiopathic, as distinguished 
from symptomatic fever; and it is easy to understand, that its 
effect on any one of these may become so intense as to be dan- 
gerous. The sedative effect on the heart is often such as to 
enfeeble, and sometimes such as nearly to suppress, the febrile 
reaction, as in congestive fever ; that on the brain may produce 
fatal coma, as in some cases of nervous fever, independently of 
any effusion or organic lesion in the brain ; that on the vital func- 
tions going on in the capillary vessels may be such, and so long 
continued, as to cause fatal inanition and exhaustion, as in some 
cases of fever, fatal merely by reason of the long endurance of the 
disease, without failure of the functions of any one organ in par- 



70 GENERAL DOCTRINES OF FEVER. 

ticular. All this is in accordance with what we see in cases where 
we know that the blood is morbidly altered in constitution, par- 
ticularly Ischuria Renalis, or disease of the kidneys. 

In most cases of fever, however, the danger is not produced 
solely in this way; but appears manifestly owing to a combination 
of the enfeebled state of the circulation, with peculiar derange- 
ment of the functions of individual organs, consequent on the 
attendant inflammations there, the symptoms, and post-mortem 
appearances of which have been already described. In conse- 
quence of this combination, we have three distinct modes of fatal 
termination of fevers, which are often blended together, but in 
some cases are quite separate and easily distinguished; and which 
are clearly illustrated by the different kinds of sudden or violent 
death formerly described— and by what has been said above of 
the morbid appearances left by fatal fevers. These are, 1. The 
death by coma, referable partly to the peculiar action of the cause 
of fever on the brain, but partly, also, to increased determination 
of blood thither, or inflammatory action or effusion there ; 2. The 
death by asphyxia, referable partly to the enfeebled state of the 
circulation, and want of power in the heart to propel the blood 
through the lungs, but partly also to bronchitis or pneumonia. 
3. The death by mere asthenia, referable partly to the deleterious 
effect of the morbific cause on the circulation, but frequently 
also in part to various local inflammations, prolonging the febrile 
state ; and especially to the inflammations and ulcerations in the 
mucous membrane of the intestines, which appear to have in this, 
as in other cases, a peculiar sedative, and what was formerly 
designated as a sympathetic, effect on the heart's actions. 

It was already stated, that these inflammations during the state 
of fever, are so far influenced by the altered condition of all vital 
actions in the capillary vessels at that time, that the local effects 
which they produce differ materially from those which follow 
inflammation of the same parts in a system free from general 
fever— as is seen, e. g., in watching the progress of a parotid, or 
other external abscess, commencing during the febrile state, but 
only suppurating fairly when that state has subsided. Never- 
theless, the internal inflammations often attending fever are quite 
sufficient, when their effect is combined with the generally en- 
feebled state of the circulation, to cause great danger. 

The nature of the connection between these local inflammations 
and the general fever is often obscure. In many cases, especially 
when the bronchise and lungs are affected, early in fever, they 
are evidently produced by a different cause, (chiefly cold applied 
before the onset, or during the course of the disease,) and only 
accidentally combined with the fever ; but in other cases they may 
probably be regarded as effects of the general fever. The deter- 
mination of blood to the head, and consequent slight inflammation 



EXANTHEMATOUS OR ERUPTIVE FEVERS. 71 

and effusion, seem often to be of this description, and are analogous 
to what sometimes happen in inflammatory diseases of other 
organs than the head. The peculiar condensation of the lowest 
portions of the lungs, in the later stage of fever, and its distinction 
from true hepatization, were already considered. The reproduc- 
tion in any part of the body, of inflammatory action which has 
recently subsided there, appears to be an effect rather than a 
mere accompaniment of fever. And the peculiar inflammation 
of the mucous glands and membrane of the intestines, when it 
takes place late in the disease, may be suspected to depend very 
much on the bile, and other irritating contents of the intestinal 
canal, passing over a membrane, which, in consequence of the 
feeble circulation, the blunted sensation, and the deficient secre- 
tion, has lost much of its natural protecting mucus ; and resting 
longest on that portion of the canal where we know that, from 
the action of the ileo-csecal valve, there must be a delay of the 
feces ; and to be analogous to the inflammation of other mucous 
membranes, consequent on section of their sensitive nerves — and 
to that which precedes death by starvation. 

On this supposition, inflammations of the mucous membrane of 
the intestines, occurring towards the close of protracted fevers, 
will stand in nearly the same relation to them as the inflammation, 
ulceration, and gangrene, from pressure on external parts ; which 
are very common, and often constitute a great part of the danger 
in such cases. 

These relations between idiopathic fever and the concomitant 
local inflammations are of great practical importance ; and the 
chief difficulty and nicety in the treatment of fever, lie in deter- 
mining how far the danger depends on such local affections as 
demand evacuations, and how far on the effect produced on the 
system by the morbific cause, which will often spontaneously 
abate, and often demands remedies of the opposite class." {Out- 
lines, &c, Am. Ed., p. 129.)] 



IV. EXANTHEMATOUS OR ERUPTIVE FEVERS. 

Modern nosologists restrict exanthematous fevers to certain 
febrile diseases accompanied with efflorescence of the skin, (com- 
prehending small-pox, measles and scarlet fever,) and allied to 
each other in the following circumstances : 

1. Though the eruption is of a defined character, it is preceded 
by a characteristic group of febrile symptoms, the fever pursues 
a definite course, and the exanthema passes through a regular 
series of changes. 2. They occur only once (with very few ex- 
ceptions) during life. 3. Almost all mankind are susceptible of 
them. 4. They are propagated by a specific contagion. 



72 GENERAL DOCTRINES OF FEVER. 

1. The defined character of the eruption, the remarkable com- 
bination of symptoms which attends the eruption, and the pre- 
cision with which the several changes or phases of each disorder 
occur, are most remarkable. The eruption of small-pox appears 
on the third day from the commencement of febrile commotion, 
and maturates or culminates on the tenth. In measles the fever 
rages in the system for four days before its specific eruption is 
developed, and three days suffice for the completion of its course. 
The efflorescence of scarlatina is perceptible on the second day, 
and begins to disappear on the fifth from the first occurrence 
or rigour of sickness. The course of the fever and the series 
of changes which the eruption undergoes are alike fixed and 
uniform, being in all important points uninfluenced by age, 
climate, season, or habit of body, and admitting only certain 
modifications from causes altogether unknown or imperfectly 
understood. 

2. The second common character of the true exanthemata is 
founded on the law of non-recurrence. Immunity from second 
attacks of the same malady is a very remarkable principle in 
pathology. Mankind have by common consent attributed the 
power of conferring immunity from second attacks to three only 
of the many diseases to which we are liable — viz., to small-pox, 
measles, and hooping-cough. It constitutes undoubtedly a most 
important feature in the medical history of these disorders, and 
by virtue of it they are, to a certain extent, isolated from other 
maladies. The same property belongs, though in unequal degrees, 
to three other forms of febrile disease — viz., to yellow fever, to 
the plague, and to scarlet fever. It is more striking in yellow fever 
than in plague ; more observable in the plague than in scarlet 
fever ; but in all, the susceptibility to future attacks is either 
greatly lessened, or entirely removed, by once undergoing the 
disease. The doctrine of immunity from second attacks, though 
generally predicable of small-pox and measles, is, even in those 
diseases, liable to certain exceptions, as will be more fully ex- 
plained afterwards. 

3. Universal susceptibility is the third character of the exanthe- 
mata. The exceptions to this law, in the instances of small-pox 
and measles, are very few, and there is great reason to believe, 
that in many of these excepted cases, the inaptitude to receive 
the disease arises from temporary causes ; and ceases in the 
course of a few months, or possibly not until after the lapse of 
years. The principle is not of such general application in the 
case of scarlatina. 

4. The exanthematous fevers are propagated by contagion. 
The power of producing a contagious matter is one of the most 
striking characters of small-pox, and in the phenomena of inocu- 
lation we possess the most convincing proof of the truth of the 



CLASSIFICATION OF FEVERS. 73 

principle. The evidence in favour of the possibility of inoculat- 
ing, or rather of artificially exciting, the measles is strong, though 
still open to some objections. The instances of the spreading of 
scarlet fever by personal intercourse are so numerous and unequi- 
vocal, that no enlightened pathologist of the present day hesitates 
to acknowledge the fact. Some contagions develop themselves 
quickly, such as those of scarlet fever and plague, which generally 
require from four to six days for their incubation ; sometimes, 
however, more especially in scarlet fever, the period has been 
longer deferred. Others, as small-pox and measles, require nearly 
a fortnight for their perfect development. Some contagions, 
however, remain latent in the constitution for three, four or six 
weeks, but each of these respective periods is subject to certain 
modifications, which will hereafter become objects of special 
investigation. 



[V. CLASSIFICATION OF FEVERS. 

The simplest arrangement, and perhaps the best for practical 
purposes, is that founded on the peculiar phenomena which are 
constantly presented by the different forms of fever, constituting 
the types. In one variety, we have the febrile phenomena in- 
terrupted absolutely or incompletely at certain periods ; whilst in 
another, the train of phenomena proceeds in an uninterrupted 
series ; and a third is accompanied with a peculiar and charac- 
teristic eruption. The order that we shall observe, therefore, 
will be : 

I. Continued Fevers. 
II. Periodical Fevers. 

III. ExANTHEMATOUS OR ERUPTIVE FEVERS.] 



74 



CHAPTER II. 

CONTINUED FEVER. 

Continued Fever may be defined nearly in the same terms 
with those formerly employed in the definition of fevers gene- 
rally. It is a disease in ivhich, after a precursory stage of 
languor, weakness, and defective appetite, acceleration of the 
pulse takes place, with increased heat, great debility of the 
limbs, and disturbance of most of the functions, without pri- 
mary local disorder, and without well-marked remissions. It 
has been already stated above, that none of these characters is 
absolutely invariable. Thus the appetite is occasionally not at 
first affected; the strength is at times so little reduced in the 
early days, that a man in the incipient stage has been known to 
walk forty-five miles within as many hours ; the pulse not un- 
frequently does not rise beyond seventy ; the heat is often im- 
materially increased ; the debility of the advanced stage may 
disappear for a time in connection with active delirium : local 
inflammations frequently concur with the general fever espe- 
cially when fully formed ; and very distinct remissions are often 
enough observed towards the commencement, and sometimes 
throughout the whole course of the fever. The least invariable 
character is disturbance of the functions generally ; for it seldom 
happens that the functions of the digestive organs and of the skin 
are not essentially deranged, and the clearness and precision of 
the external senses impaired. 



I. SYMPTOMS OF CONTINUED FEVER. 

There is but one way of taking a comprehensive and simple 
view of the symptomatology of continued fever ; which is, by 
considering first the essential phenomena of its three leading 
varieties or types, and then the phenomena which are incidental 
or accessory. It seems advisable, too, that the symptoms of the 
three types be viewed in succession or close relation to each 
other; because they are, at least in the opinion and according to 
the experience of the writer, mere varieties of one fundamental 
disease, originating in the same causes, and constituted merely by 
differences in those obscure co-operating influences which are 
alluded to when we speak of epidemic constitution. This is the 



EPHEMERAL FEVER. 75 

conclusion to which every one will arrive, who has had an op- 
portunity of closely watching in hospital practice a long series of 
epidemics, similar to those which have ravaged the city of Edin- 
burgh between the years 1817 and the present time. For the 
disease has been clearly seen, during that interval, to pass very 
gradually from a type in which pure inflammatory fever was 
exceedingly common, first into one composed of the same fever 
in the early stage, and of adynamic fever in the advanced stage, 
and at length into a type of nearly pure adynamia or typhus, 
which has prevailed for a few years past. And these changes 
have thus gradually taken place, without any other essential al- 
teration in the history of the disease, but especially without any 
change in its apparent mode of propagation and causes. 



[A. EPHEMERAL FEVER. 

Syn. Diary Fever. Febricula, Ephemera, Febris diaria. Simple Fever, of For- 
dyce. Eintagige Fieber, Germ. Fievre Ephemere, Fr. Effimero, Ital. Efemera, 
Span. 

Ephemeral Fever is characterized, according to Dr. Copland, 
by increased frequency and strength of pulse, with heat of 
skin, headache, thirst, and white excited tongue; terminating 
in perspiration generally within twenty -four hours. 

It is a frequent disease in this country, and is the slightest as 
well as simplest of all primary febrile disorders, and is so named 
from its seldom lasting longer than a single diurnal revolution. 

Causes. — It is often difficult to discover any unequivocal cause 
for an attack of ephemeral fever. It affects chiefly children and 
young persons, and frequently seems to be excited by the atmo- 
spheric vicissitudes during the irregular weather of the spring 
months in temperate climates. Excessive muscular and mental 
exertion, from prolonged exercise, or intense study ; exposure to 
sun ; the intemperate use of alcoholic drinks ; disorder of the 
digestive organs, from repletion, or the nature of the ingesta, or 
congestion of the liver, or a vitiated condition of the secretions of 
the prima? viae, are all capable of producing an attack. The 
febrile condition, often excited in puerperal women on the first 
secretion of milk, has, by most writers, been classed under this 
head. 

Symptoms.— In the acuter form of ephemeral fever the inva- 
sion is generally sudden, the attack commencing with a chill ; but 
in mild cases there are lassitude, yawnings, general malaise, with 
a feeling of irritation, or excitement. These symptoms, or the 
initial chill when occurring, are soon succeeded by heat of skin, 



76 CONTINUED FEVER. 

and cephalalgia. The face is flushed, and animated, but the ex- 
pression is natural; the pulse is frequent, strong, and full ; there is 
frequently pain in the small of the back, with a sense of great 
weariness and soreness in the limbs • the thirst is intense ; there 
is no appetite; the tongue is white; the papillae enlarged; the 
'mouth is dry, with a bad taste ; and the urine scanty and high 
coloured. The skin, though hot, is usually soft. In children, 
and in some women, when the attack is severe, slight delirium 
may supervene for a short time. Exploration of the chest and 
abdomen discovers no lesion of the contained organs. These 
symptoms, with restlessness, languor, want of sleep, and general 
uneasiness, having lasted for six, twelve or eighteen hours, the 
fever begins to diminish ; the skin becomes moist ; the urine 
more copious, and depositing a sediment, and the free perspiration 
occurring, the attack subsides within twenty-four hours, though 
occasionally it continues for several days, assuming the charac- 
ters and type of Inflammatory fever. Sometimes the patient 
continues listless and feverish on the following day ; does not 
feel disposed to quit his bed ; and passes an uncomfortable day, 
with slight febrile exacerbation towards evening. After a good 
night's rest, however, he usually awakens refreshed, and well. 

Diagnosis.— It is often extremely difficult to decide, at the 
outset of an attack, whether it is a case of ephemeral, periodic, or 
continued fever. The absence or presence of the causes just 
enumerated, may assist our inquiry. Whilst the non-occurrence 
or insignificance of the initial chill, and the continuation of the 
fever beyond six or eight hours will often enable one to distin- 
guish it from intermittent fever; the amount of vascular excite- 
ment, the slight depression of the nervous powers, and the very 
transient duration of the premonitory symptoms will serve to 
distinguish it from the more serious varieties of fever. 

Prognosis. — The prognosis is of course favourable ; but it 
should be borne in mind that sometimes the disorder is prolonged 
beyond the diurnal period, and assumes the characters of Syno- 
cha. 

Treatment. — Confinement to bed, abstinence from food, and 
demulcent drinks are often all that is necessary for an attack of 
ephemeral fever, whose tendency is towards a favourable termi- 
nation, and which, indeed, requires little or no treatment. If, 
however, the disorder has followed exposure to a hot sun, and 
there is much vascular excitement, with cerebral symptoms, 
blood-letting may be advisable, together with active purging, 
and cold applications to the head. If the attack be subsequent to 
a debauch, the stomach and bowels should be freely evacuated. 
Where the stomach is irritable, small doses of the nitrate of potash 



SYNOCHA OR INFLAMMATORY FEVER. 77 

in combination with the muriate of ammonia may be admin- 
istered. — 

R. — Potassee nitratis gr. xx. 

Ammoniae hydrochlor. gr. xij. 
Aquae camphorae %vj. 
Aquae fex. 
M. 
Sig. To be repeated every four hours. 

When the skin is dry and unperspirable, diaphoretics should be 
administered. 

K. — Sue. Km on. recent, f^iij. 

Potassae bicarb, q. s. ad sat. 

Spr. aether, nit. f gij. 

Syr. simp., f !§i. 

Aquae fjiij. 
M. 
Sig. — A tablespoonful every two hours. 

Cold, or even iced drinks may be freely allowed, when wished 
for, together with small quantities of soda water.] 



B. SYNOCHA, [OR INFLAMMATORY FEVER. 

Syn. YLaZjot;, Hippocrates; Synochus Imputris, Galen; Febris Sanguinea, Avicen- 
na ; Synocha Biliosa, F. Sanguined, Leunert ; Fievre drdente, Quarin ; F. Septinaria, 
Plater ; jP. Continua Inflammatoria, J. P. Frank ; Fievre angiotinique, Pinel ; Fievre 
Inflammatoire, Fr.; Synoshische, Entzundliche Fieber, Germ; Febbre Jnflammatorid, Ital.] 

It has become fashionable of late with medical authors to doubt 
or deny the existence of such a fever as synocha or inflamma- 
tory fever, or at least to limit it to warm climates, and to admit 
ephemeral fever alone as an exemplification of it in temperate 
countries. But this is a mistake, arising simply from limited op- 
portunities of observation, and the disregard of epidemic differ- 
ences occurring in different years and different places. In the 
Edinburgh epidemic of 1817-20, a fever purely inflammatory, 
or with complications, but altogether divested of the typhoid 
character, was so .prevalent, that from a numerical statement 
kept for some time by the writer, it formed between a fifth and a 
sixth of the patients in the infirmary and fever hospital. In the 
subsequent epidemic of 1S26-9 the same form was observed, 
but by no means in so great a proportion ; and since then it has 
gradually disappeared, and is now scarcely ever met with. 
There is no room, therefore, for the doubts which have been 
lately thrown over the accuracy of Dr. Cullen's classification 
and delineation of fevers, from the apparent impossibility of 
finding his synocha or inflammatory fever. In this, as in other 
respects, Cullen's delineations are true to nature, whatever may 
be thought of his speculations in regard to the proximate cause 
or essence of fever ; and, indeed, little has been hitherto done 



78 CONTINUED FEVER. 

to improve the leading features of his classification, and least of 
all by those who have slighted his admirable descriptions of 
disease. 

Synocha may be defined nearly in the language of Cullen, a 
fever consisting of a state of chilliness or rigor, succeeded by 
great increase of heat, frequent hard pulse, redness of the 
urine, little disturbance of the mental faculties, and tending 
in general to terminate by sweating. 

Symptoms. — It commences for the most part abruptly. The 
patient is suddenly seized with an undefinable sense of feeble- 
ness, languor, and oppression, disinclination for food, sickness, 
and perhaps also vomiting, frequency and feebleness of the pulse 
— followed speedily by pain in the back, headache, a peculiar 
sense of weight or rending in the limbs, coldness in the back, 
general chilliness, and often absolute shivering, with paleness of 
the features, and the cutis ancerina. When these symptoms 
have lasted for a period varying in general from one hour to half 
a day, the ^coldness passes off; the pulse, from being soft and 
fluctuating, becomes hard, sometimes full and bounding, often 
small, wiry and incompressible, generally very rapid, sometimes 
so frequent as 140, 150, or even 160 ; the tongue dry and covered 
with white or yellowish fur ; the skin parched, red hot, often 
pungently so ; the animal temperature elevated to 102°, 104°, and 
occasionally so high as 107°. At the same time there is increased 
headache, with giddiness, throbbing of the temples, and flushing 
of the features ; great undefinable uneasiness in the limbs, occa- 
sioning frequent change of posture ; an intense sensation of heat; 
whiteness and dryness of the tongue, with urgent thirst and 
desire for cold liquids, but a total loss of appetite; constipation; 
redness and scantiness of the urine, often with a tendency to dis- 
charge it frequently ; extreme irritability of the senses of sight 
and hearing, more especially remarked in the irritable constitu- 
tions of persons in the better ranks, so that in them the faintest 
light, and any regularly recurring sound are insupportable. An 
exacerbation commonly occurs in the evening or early part of 
the night, and a remission early in the forenoon, but the difference 
is frequently trifling. The fever is thus fully formed in general 
in the course of the first evening ; but not unfrequently the hot 
stage is completely developed in an hour or less; and on the other 
hand, it may be imperfectly presented till the second day. There 
is not necessarily any local pain, except headache and a sense of 
soreness or rending of the back and limbs. Vomiting and sick- 
ness are seldom present, or at least troublesome, till the second 
or third day; are often wanting throughout most of the attack; 
and frequently are insignificant till blood-letting has been prac- 



SYNOCHA OR INFLAMMATORY FEVER. 79 

tised, after which vomiting is often frequent and severe. The 
faculties of the mind are for some days unaffected, except by- 
restlessness and anxiety, and they may continue undisturbed 
even during the whole course of the fever ; but frequently after 
a few days there is a tendency to delirium, and at times the 
delirium is active, and indicated by frequent incoherent talking, 
together with a disposition to roam. Very often, however, the 
tendency of the patient to leave his bed, from mere febrile 
restlessness and desire of change of posture, is mistaken for deli- 
rium. Delirium occurs most frequently for a short time before 
the hot stage of the fever is about to be resolved. The blood 
from a vein is commonly very florid— sometimes, in young adults 
with high reaction, so unusually bright, that the surgeon is apt to 
imagine he has opened an artery instead of a vein. It coagu- 
lates in general firmly, with little separation of serum ; but not 
unfrequently shows the buffy coat, contracted clot, and distinct 
separation of serum observed in acute local inflammations. 

[Andral and Gavarret have carefully analyzed the blood in 
this disease, and give the following account of their researches. 

They made nine analyses of the blood of six persons. The 
fibrin did not exceed the normal amount in any instance, (in one, 
however, it amounted to 3-2 ;) in three cases it was a little below 
the standard, but exceeded 2 ; in two cases it was rather less than 
2 ; and in one case as low as 1-6. The amount of blood-corpus- 
cles was lower in only two cases than in normal blood ; in the 
others it was more or less increased, and in the blood in which 
the fibrin amounted to only 1-6, the corpuscles amounted to 
157-7, which if the fibrin were estimated at 3, would give the 
enormous amount of 296. We have only one instance in 
typhoid blood of so high a proportion. The amount of the 
residue of the serum is increased, rather than diminished, and 
the same is the case with the solid constituents of the blood 
generally. 

Their analyses gave the following results : 







Date of 








Blood- 


Residue 


Venesection 




the disease. 


Water. 


Solid residue. 


Fibrin. 


corpuscles. 


of serum. 


1st Case 


1 


7 


766-2 


233-8 


30 


143-5 


87-3 


2d " 


1 


8 


769-5 


230-5 


1-8 


136-4 


92-3 


3d " 


1 


8 


761-3 


238-7 


2-9 


142-7 


931 


4th " 


1 


15 


770-8 


229-2 


3-2 


137-9 


88-1 




; i 




785-6 


213-4 


2-3 


125-4 


86-7 


5th Case < 


2 




788-3 


211-7 


2-2 


1240 


85-5 




1 3 




790-8 


209-2 


21 


123-0 


85-5 


6th Case 


\ 1 




744-2 


255-8 


1-6 


157-7 


96-5 


1 2 




779-7 


220-3 


2-1 


129-3 


88-9 



The inorganic constituents of the residue of the serum amounted 
on an average to 7*5§, which corresponds with the proportion in 
typhoid fever. 



80 



CONTINUED FEVER. 



Jennings* has analyzed the blood of a girl aged 14 years, suffer- 
ing from continued fever. He found it composed of: 

Water - - ,. 8560 

Solid residue - - - 144-0 

Fibrin ... - 2-0 

Fat - 30 

Albumen - 37-0 

Blood-corpuscles - - 91-0 

Extractive matter - - 3-0 

Alkaline salts - - 3-8 

Earthy salts - - - 1-0 

Becquerel and Rodier have analyzed the blood of 3 men and 
2 women, suffering from ordinary continued fever. The mean 
composition of the blood of the 3 men is given in the following 
table : 

Density of defibrinated blood - 1056-8 

Density of serum - - - - - '1025-5 

Water 781-6 

Solid constituents ----- 218-4 

Fibrin 2-8 

Fat - 1-7 

Albumen ------ 65-7 

Blood-corpuscles ----- 142-4 

Extractive matters and salts - 5-8 

Here we see that the fibrin and albumen remain nearly normal, 
while the corpuscles, instead of diminishing, are slightly above 
the average (their numbers being 146, 142, and 138). The fatty 
matters and salts offered no peculiarity. 

They give the following particulars regarding the blood of the 
two female patients. 

The corpuscles were augmented (135-5) in the first case ; nor- 
mal (125-5) in the second: fibrin normal (1-9) in the first; doubled 
(3-6) in the second: albumen normal (73 and 70) in both. The 
serum was turbid in both cases. In the case in which the cor- 
puscles were 125, the clot was firm and resisting, in the other it 
was soft and diffluent. 

Andral and Gavarret also made 21 analyses of the blood of 11 
persons labouring under continued fever. 

They divide their analyses into two series ; one containing the 
results obtained when the blood was taken nearly at the termina- 
tion of the disease ; the other when certain inflammatory states, 
as angina, erysipelas, bronchitis, &c, had supervened. These 
researches exhibit less of the characters of hypinosis than those 
instituted on the blood at the commencement of continued fever, 
which, in the first series, may be due to the circumstance of the 
disease being on the decline ; and in the second, to the inflamma- 

* [Course of Lectures on the Physiology and Pathology of the Blood, by H. 
Ancell. The Lancet, 1840, p. 339.] 



SYNOCHA OR INFLAMMATORY FEVER. 81 

tory complication. In both series the fibrin exceeds the normal 
amount, and in both, the amount of corpuscles is, in part also be- 
low the standard.] 

The terminations of this form of fever, are essentially three in 
number, abrupt departure in connection with some critical dis- 
charge, gradual mitigation and disappearance, without particular 
increase of any of the excretions or any adventitious evacuation, 
and gradual transition from the purely inflammatory character 
into the typhoid type. But when the last of these courses is 
pursued, the disease ceases to be synocha, and is characterized 
as synochus. A common course is gradual mitigation of the 
symptoms between the seventh and fourteenth days, sometimes 
without any critical discharge, yet sometimes too in concurrence 
with occasional attacks of sweating. If the fever lasts, however, 
much longer than seven days, it commonly puts on, sooner or 
later, the typhoid or adynamic character. If, on the contrary, 
there is decided amelioration earlier than the seventh, or even 
on the seventh day itself, the amendment usually becomes com- 
plete, and occurs in connection, either with a profuse attack of 
sweating, or sometimes, though far more rarejy, with an attack 
of diarrhoea or of epistaxis. The most frequent, and by much the 
most remarkable, variety of this type of fever, is that which ter- 
minates abruptly by sweating. Sometimes so early as the fourth 
day, very rarely earlier; most generally on the fifth or sixth, 
sometimes on the seventh or eighth, but seldom at a later period, 
the skin becomes moist, along with sudden abatement of the 
headache and jactitation ; and a profuse discharge of sweat fol- 
lows, which lasts for two, three, four, six hours, or upwards, and 
leaves the patient languid and exhausted, but otherwise almost 
free of every complaint, and, in particular, with the pulse at the 
natural standard. It is not uncommon to observe a sweat of four 
hours change the condition of a patient from all the tortures of 
an ardent fever, with the pulse at 140, to a state of complete re- 
pose and absence from all suffering except from extreme languor, 
with the pulse at 70. In a few rare cases the fever is carried 
off in like manner by critical diarrhoea or critical epistaxis. 

[A critical hemorrhage is not an uncommon termination of this 
disease. In young persons epistaxis is most frequent; in adults 
a hemorrhoidal flux ; whilst in females, the sanguine discharge 
takes place from the genital organs.] 

Convalescence from an attack of fever of this kind is always 
slow, several weeks being requisite for restoration of the strength, 
even where the patient has not been more than five or six days 
under the proper febrile symptoms. Relapse too is common, 
and it usually takes place about the fourteenth day ; nor does 
any care on the part of the patient to avoid the causes of ex- 
6 



82 CONTINUED FEVER. 

citement or fatigue, seem to have any tendency to diminish the 
chance of relapse. This commences, for the most part, with 
severe shivering ; symptoms succeed similar to those already 
mentioned as characterizing the primary attack ; and the disease 
is finally resolved by another fit of profuse perspiration, gene- 
rally in the course of the third day from the reappearance of 
rigors. 

Such is a sketch of inflammatory fever in its pure state, as it 
occurred in a considerable proportion of cases of epidemic fever, 
especially among young adults, both in Edinburgh and in other 
parts of Great Britain and in Ireland, between the years 1817-20, 
and likewise, though to a less extent, in the succeeding epidemic 
of 1826-9. In many instances, however, the disease was not 
altogether pure. More generally it was attended, in one part or 
another of its course, with symptoms of local inflammation — most 
frequently in the chest, occasionally in the peritoneum, more rarely 
in the larynx, often in the tonsils, seldom in the parotid gland, and 
very seldom in the head. Such local affections, of which catarrh, 
pneumonia, and pleurisy, were the most common, did not show 
themselves till the fever had lasted for a few days ; they frequently 
disappeared some time before the cessation of the febrile symp- 
toms ; and they were, for the most part, very easily removed by 
general or even local depletion. In a few rare cases the local in- 
flammation went on where the fever was checked. Rheumatic 
attacks were common during convalescence; but they were seldom 
attended with any febrile disturbance of the circulation. Cases of 
pure fever were most frequent in young persons of the better 
ranks, who were not exposed to the ordinary co-operating causes 
of local inflammation. 

[When a case of inflammatory fever extends beyond four or five 
days, there is a probability of the existence of some latent inflam- 
mation, consecutively developed. It is of great importance that 
the internal organs should be carefully explored from day to day ; 
for, whilst simple continued fever may last for several days without 
implicating any viscus, it should be borne in mind that the liability 
to visceral phlegmasia is in proportion to its duration.] 

Diagnosis. — Synocha may pass by insensible shades, first, into 
synochus; secondly, into gastric or gastro-intestinal fever ; and, 
thirdly, into the acute or febrile inflammations. It is seldom diffi- 
cult to distinguish idiopathic local inflammations from primary 
inflammatory fever ; yet sometimes the diagnosis is obscure. The 
chief distinctions are, that in the latter the local inflammation is 
slight compared with the general febrile state ; that it arises con- 
secutively to the fever, and may cease without the latter disappear- 
ing or even abating ; and that there is throughout the disease, but 
especially at the beginning, more oppression, nervous exhaustion, 



SYNOCHA OR INFLAMMATORY FEVER. 83 

and restlessness, together with a peculiar expression of the coun- 
tenance, which a practised person may for the most part readily 
recognize. Gastric fever is sometimes distinguished from synocha 
with great difficulty. The pyrexia, however, is seldom so violent, 
nor the countenance so oppressed, nor the sense of rending and 
restlessness of the limbs so distressing ; neither is there so marked 
a tendency to resolution of the disease by sweating ; while, on the 
other hand, the tongue is more loaded with yellow sordes, or red 
and raw-looking — the local symptoms referable to the abdomen 
are generally more marked, though this is far from being invaria- 
bly the fact — and there is usually a much more distinct tendency 
in the fever to put on the remittent type. There is never any 
difficulty in distinguishing true inflammatory fever from synochus; 
but the former passes insensibly into the latter, by the superven- 
tion of typhoid symptoms towards the commencement or termina- 
tion of the second week ; and, according to the degree of that 
secondary stage, the case may be regarded as belonging either to 
one type or the other. 

[To establish a differential diagnosis it is first necessary to 
ascertain whether the febrile movement is essential, or dependent 
on some local phlegmasia. Simple inflammatory fever is distin- 
guished from the fever preceding the eruption of variola, measles, 
or scarlatina by the special character of the prodromes, to be here- 
after indicated, as well as that of the fever. It is by no means 
unfrequently confounded with typhoid fever assuming, at the com- 
mencement, the inflammatory type. When treating of this latter 
affection, the differential signs will be pointed out. 

Prognosis. — The prognosis in simple inflammatory fever, of 
temperate climates, is always favourable, except when complicated 
with inflammation of some important viscus. 

Causes. — Inflammatory fever commonly attacks young, vigor- 
ous and plethoric persons, who lead a sedentary and luxurious 
life. An attack is often sudden ; following a debauch, bodily or 
mental exertion, or the suppression of an habitual sanguine dis- 
charge. It sometimes occurs epidemically, especially in dry or 
elevated situations, and during the spring of the year. 

Treatment. — A slight attack of inflammatory fever requires 
but little treatment. Confinement to bed, an antiphlogistic regi- 
men, cold acidulated drinks, with an occasional saline purge are 
all that is indicated. If there is high vascular action, blood-letting 
should be early resorted to, and the first bleeding ought to be 
sufficient to make a decided impression. If the patient complain 
of severe and continued cephalalgia, local bleeding, by leeches 
or cups, with the application of cold to the head, and stimulating 



84 CONTINUED FEVER. 

pediluvia may be employed. If the attack is consequent to a 
suppressed hemorrhage, an effort should be made to recall the san- 
guine discharge. Consecutive local inflammations should be early 
and actively treated.] 

The Stnocha of hot climates seems not to differ essentially from 
the disease here described. The tendency to diaphoretic crisis, 
however, is less marked ; there is not the same frequency of re- 
lapse ; neither is it observed that relapse is apt to occur after a 
fixed interval, rather than at other irregular periods of convale- 
scence. It is also said by Dr. Stevens, that it is never ushered in 
by rigors, and that the blood, though always unusually florid, 
never presents the buffy coat of inflammation. Farther, while the 
inflammatory fever of hot climates evidently arises from atmo- 
spherical vicissitudes, or such other causes, and independently of 
communication with the sick, the synocha which is described 
above often originates as unequivocally in infection, as will be 
more fully explained under the head of the Causes of Fever. 

[This variety of Inflammatory Fever differs from the fore- 
going, or mild form, only in degree. The disease has been 
described by the names of Synochus Causonides, by Gilbert ; 
of Synocha Causodes, by Manget ; of Synocha Jlrdens, by 
Sauvages; of Endemial Causus, by Mosely; of Inflammatory 
Endemic, by Dickenson ; and is very generally known in warm 
climates, as the Climate or Seasoning Fever. It may be said to 
be endemic in hot countries, in dry seasons and localities, and 
attacks strangers who visit them from the north. It has been 
confounded with both the Marsh or Remittent Fevers, and with 
the epidemic Yellow Fever. It attacks, as has been stated, those 
recently arrived, and more especially the young, the robust, the 
plethoric, the intemperate, and those exposed to the sun, and to 
the night air. It is not produced, Dr. Stevens asserts, by marsh 
poison, or contagion, but by long-continued, excessive heat, act- 
ing under peculiar circumstances, on the bodies of unseasoned 
strangers lately arrived from northern countries. " That the 
Climate Fever," says Dr. S., "is not produced by the marsh 
poison, is evident, not merely from the symptoms, but also from 
the fact that it is generally met with in hot and dry situations, 
such as the central part of the town of St. Thomas, where the 
marsh fever is not known as an endemic.'"* Those who have 
had the Climate Fever are not susceptible of it a second time, 
unless they leave their own residence, and return to it after a 
prolonged sojourn in a northern climate. According to the 
same authority, it only occurs as an epidemic during the hot 
months, when the thermometer is upwards of 88° during the day, 

* [Observations on the Healthy and Diseased Properties of the Blood, 1832.] 



SYNOCHA OR INFLAMMATORY FEVER. 85 

and at least 80° during the night. It was prevalent, during the 
wars of the French Revolution, among the British troops and 
seamen in the Mediterranean. The causes producing the disorder 
rarely affect the older residents, and never the natives of the 
country, or the blacks ; women and children, the aged and feeble, 
are much less liable to be attacked than the robust and plethoric. 
Dr. Copland, who had extensive opportunities of seeing this 
disease in 1817, thus describes it: — "The aggravated form of 
inflammatory fever is seldom preceded by very marked premoni- 
tory symptoms. The attack is usually sudden. Giddiness, faint- 
ness, and general uneasiness, sometimes, however, precede it for 
ten or twelve hours. There is occasionally a slight and brief 
chilliness at the commencement, especially in the less violent 
cases, rapidly followed by a sense of universal heat ; by flushed 
face, frontal headache, and vertigo ; by inflamed, heavy eyes, and 
great sensibility to light and sound ; by pain in the occiput, neck, 
back and limbs ; and by a strong, full, hard, and accelerated pulse. 
A sense of heat, oppression, pain, or anxiety is felt at the pras- 
cordia, sometimes with a dry cough, and pain in the side ; respi- 
ration is quick, laborious, suspirious, or anxious ; the tongue is 
white, excited, and its edges red ; the fauces are arid, thirst urgent, 
and skin hot and dry; the urine is scanty, the bowels costive ; and 
there is generally nausea, but seldom vomiting until some time 
after the attack. If the disease be not mitigated by treatment, the 
patient becomes extremely restless, the headache is rending and 
intense, vascular action is excessive, and the heat very great. 
Vomiting now supervenes, and follows the ingestion of whatever 
is taken to allay the urgency of thirst. The matters thrown off" 
are generally tinged with bile, and a bilious yellow suffusion of 
the skin is frequently observed. Bilious vomiting and purging 
occasionally occur with the yellowness of the surface, and, in the 
slighter cases, become a favourable crisis. There is often great 
drowsiness, but no refreshing sleep. These symptoms of exces- 
sive excitement proceed with various degrees of violence, and 
occupy a period of from twenty-four to sixty hours, but most 
commonly from twenty-four to forty-eight hours. During this 
period blood taken from a vein is remarkably florid, warm, and 
fluid. The fibrin coagulates firmly, but the crassamentum is 
without crust, and is rarely cupped. The excitement, having 
reached its acme, is quickly followed by exhaustion. This is 
indicated by a subsidence of the most urgent symptoms : the pain 
and heat are lessened ; the skin becomes damp or clammy ; and 
the patient has a sense of cold or slight chilliness. This delusive 
remission is a state of great danger ; in some cases, it passes into 
rapid sinking — into a speedily fatal collapse ; but, more generally, 
irregular determinations of blood, or indications of especial lesion 
of particular parts, are evinced before death ensues. With the 



86 CONTINUED FEVER. 

diminution of heat and pain, the pulse falls ; the countenance be- 
comes anxious and distressed; the eyes sunk, the pupil dilated; 
vomiting continues without intermission, especially if the cerebral 
affection has abated ; sometimes delirium is present, at others 
there is great insensibility or tendency to coma, and in these cases 
the stomach is more tranquil. Discoloration of the skin gene- 
rally takes place in this stage, appearing in yellow, yellowish 
brown, and livid patches. It never occurs in the period of ex- 
citement, for it is quite dissimilar from the bilious yellowness 
occasionally observed in that period. It is commonly attended 
by passive hemorrhage from the nose, gums, eyes, ears, &c, and 
by black and grumous vomiting. The change of colour and 
hemorrhage proceed from exhaustion of the vital influence in 
the extreme vessels, and from the changes induced in the mass 
of blood. The matters thrown off the stomach consist at first 
of ingesta and serous fluid, often coloured by bile. In a more 
advanced stage they are ropy, mixed with numerous small shreds, 
flocculi, or films, which soon acquire a dark brown, purple, or 
black colour ; but do not, at first, communicate much of the same 
tint to the fluid containing them. Afterward, the matters vomited 
are more intimately mixed ; and, from dark-coloured blood which 
has been effused into the stomach, vitiated bile, and other morbid 
secretions, assume a dark or coffee-grounds appearance. At the 
same time, dark-coloured matter, resembling tar mixed with black 
blood, is freely discharged from the bowels. The other symptoms 
characterizing this stage, and preceding dissolution, are, soft, quick, 
intermitting, or irregular pulse ; clammy, cold, or partial sweats ; 
deep and heavy respiration ; coldness of the extremities ; black 
urine, or suppression of urine ; singultus, convulsive sighs ; tre- 
mors and subsultus tendinum ; faltering speech ; low muttering 
or raving delirium ; smugglings to get up in bed ; dark or raw 
appearance of the tongue ; livid blotches over the body, particu- 
larly the preecordia ; faintings or coma, and glazed eyes. The 
blood at this period is black, thin, and dissolved, its fibrin seems 
diminished, and it does not separate into crassamentum or serum; 
or if it does, the former consists of a thin, dark jelly, with the 
black colouring matter precipitated towards the bottom of the 
vessel."— {Diet. Pract. Med., Am. Ed.) 

The chief complications are gastric and biliary disorders. 

In 1843-44 a remarkable epidemic continued fever prevailed 
in Scotland and parts of England, and was regarded by many of 
the distinguished physicians who had an opportunity of observing 
it as a fever of a different and distinct species from the common 
typhus of Great Britain. The description of Synocha just given 
by Dr. Christison, principally taken from the epidemics of 1817- 
20 and 1826-29 in Edinburgh, leaves little doubt that these epi- 



SYNOCHA OR INFLAMMATORY FEVER. 87 

demies were identical. Dr. Cormack* describes two forms of the 
disease — the moderately and the highly congestive. " The symp- 
toms of invasion are in all cases remarkably similar, both as to 
their nature, and order of occurrence. The patient is first seized 
with coldness, rigors, headache, pain in the back, and more" or 
less prostration of strength ; but the latter symptom, it must be re- 
marked, is often not at all urgent, many walking long distances 
from the country to the hospital, especially during the first days 
of the disease ; and a still greater number of the destitute town 
patients lounge about the streets after their seizure, and come into 
us on their legs. After a period varying from less than half an 
hour to several hours, the cold fit terminates, when the severity of 
the headache greatly increases, and a dry burning heat comes over 
the whole body, accompanied by much thirst and general uneasi- 
ness. The hot stage is succeeded by a sweat, usually very profuse, 
continuing for a number of hours, and seldom attended or followed 
by any relief to the headache or other pains. Sometimes, though 
rarely, there is no sweating for two or three days after the seizure. 
Occasionally, also, there is no well-marked hot stage between the 
cold and the sweating fits ; and in at least a few cases, the sweat 
breaks out on the face and upper part of the body, whilst the 
patient is yet in his initiatory rigors. It is proper to remark, that 
during the whole course of the disorder, the perspiration has a 
characteristic disagreeable smell, and is decidedly acid, as is proved 
by its reddening litmus paper, and that sometimes with intensity. 
During the three stages of the initiatory paroxysm the pulse is 
rapid, being sometimes as high as 150, seldom below 90, and com- 
monly ranging between 90 and 120. During the rigors, in several 
cases, I have found it very wiry and tremulous ; in the hot stage it 
is often hard, and not very easily compressed ; at the sweating 
period, it becomes fuller and softer, and does not exhibit that de- 
ficiency in strength, shown after, and during the perspirations of 
a more advanced period of the fever. For the first forty-eight 
hours, the tongue commonly continues moist, exhibiting at the 
same time a white or brownish yellow fur, excepting at the point, 
where there is usually a clear space, extending over a space, often 
(as in typhus abdominalis) shaped like a triangle, the extremity 
of the tongue forming the base. Afterwards, the tongue becomes 
dry, and longitudinally streaked on the centre with brown, in 
which state it continues till the approach or arrival of the crisis, 
at from the third to the ninth, but in the majority of cases, on the 
fifth day. During the first four days, some of the patients have 
occasional short rigors ; but most commonly, they are in a state 
of dry ardent fever, with occasional sweatings. These sweatings 

* [Natural History, Pathology, and Treatment of the Epidemic Fever at present 
prevailing in Edinburgh and other towns, by John Rose Cormack, M.D. Edinburgh, 
1843.] 



88 CONTINUED FEVER. 

occur, or at all events, commence in most cases, between two and 
nine, a. m ; but to this rule, there are many exceptions. In a con- 
siderable proportion, even of the ordinary and mild cases, nausea 
and vomiting usher in and attend the sufferings of the first days. 
Pain at the scrobiculus cordis generally accompanies these symp- 
toms; not unfrequently, it is present without them. A symptom 
which uniformly occurs during the first four days, is severe muscular 
and articular pain. General uneasiness, or pain in the abdomen, 
(but particularly above the pubes, and over the liver and spleen, 
when pressure is made on these regions,) are very commonly, 
but by no means uniformly met with. So long as the patients 
suffer much from the symptoms now described, they sleep badly, 
and frequently not at all, unless opiates are administered. The 
severe pains in the joints and muscles are often sufficient to 
account for the bad nights complained of; but even with those 
who do not suffer much from this cause, sleeplessness is a distress- 
ing symptom up to the crisis. A remission on the third day is 
very common. It occurred in all the cases which I have had an 
opportunity of attentively observing from the invasion onwards. 
On or about the fifth day, there is an evident manifestation of the 
violence of the disorder heing expended ; and this change for the 
better is often very sudden and complete. One day, we hear the 
patient moaning and groaning in pain ; and on the next, he is 
at ease and cheerful, his only complaints being of hunger and 
weakness. This state is generally ushered in by a copious sweat ; 
or by epistaxis or diarrhoea. The sweating was by far the most 
common critical evacuation till the beginning of October, when 
diarrhoea and dysentery, formerly rare occurrences, became com- 
mon; and at the present time (October 30) they are as usual as 
sweating. After this change, the pulse, tongue, and skin are quite 
natural ; and the facial bronzing often becomes much less striking. 
For several days, or till about the fourteenth or fifteenth day of 
the disease, there is a period of intermission, during which a great 
deal of lost strength is regained, and a steady improvement goes 
on in all respects. On, or about the fourteenth or fifteenth day 
from the beginning of the disease, the patient relapses ; or, in other 
words, has a paroxysm of fever, similar to that which began his 
first attack. The relapse takes place late or early, just according 
to the date of the first convalescence, as will be clearly seen from 
all the cases to be detailed. It sometimes happens, that the onset 
and progress of the second attack are attended by severer, and at 
other times, by milder symptoms than those of the first. In the 
relapse, the abortions most commonly take place. In it also, the 
muscular and articular pains are very often most severe. Cases, 
which in the first attack were strictly mild and ordinary, have in 
the second, become signalized by jaundice, delirium, diarrhoea, 
dysentery, and other grave symptoms. Such occurrences are. 



SYNOCHA OR INFLAMMATORY FEVER. 89 

however, not common. A large number of patients have a second 
and generally mild relapse, on or about the 21st day. As these 
relapses take place often after dismissal from the hospital, it was 
some time before I discovered the frequency of third attacks. In 
those who are young and of good constitution, the convalescence 
is rapid and complete. In the old and debilitated, it is otherwise. 

One of the most common symptoms in the highly congestive 
form of the disease, is yellowness of the conjunctiva, and of the 
whole surface of the body. It generally appears between the 
third and seventh day, and is always most intense on the face, 
neck, chest, abdomen, and thighs. The hue of the neck and chest 
is the most vivid ; then comes, of equal, or nearly equal brightness, 
the abdomen; then, somewhat fainter, the thighs; then, consider- 
ably paler still, the legs, arms, and forearms ; the hands and feet 
get their colour later, always to a much less extent, and sometimes 
not at all. The yellowness occasionally appears during the re- 
lapse, and not in the first attack. I have seen it present in both. 
Associated with the yellowness, there are generally depression, 
less or more delirium, dusky, and often porter-coloured urine, black 
melcena-like stools, and hemorrhages from some of the mucous 
membranes. In the worst of the cases, black coffee-ground like 
matter is ejected from the stomach, and passed per anum. In 
some cases, the black vomit occurs without the yellowness ; and, 
on the other hand, at the autopsy of yellow patients who have 
had no black vomit, this matter has been found in the stomach, 
and other parts of the alimentary canal. Enlarged liver and 
spleen, and tender and tympanitic abdomen are less constant, but 
still very usual symptoms in cases characterized by yellowness or 
extreme congestion. Difficult micturition has been complained of 
by several of my yellow and purple patients. With the exception 
of the purple countenance, the symptoms which usher in the con- 
gestive form of the disease, differ little from those attending the 
disorder in its milder degree. As has already been remarked, 
there is some considerable difference in the cases as to the time at 
which the yellowness appears. Generally, in the severe cases, 
there is merely a remission about the seventh day, but no inter- 
mission; and even in those who died a few days later, a slight 
amendment was noticed about the usually critical period/' 

The bronzing, leadening, or purpling of the countenance before 
and after seizure, — which Dr. C. states as a peculiarity which struck 
all the visitors to his ward, — seems to have escaped the notice of 
other writers on the subject. It reminded some of the aspect of the 
inhabitants of the marshy districts of Italy, others saw a resem- 
blance in it to the sufferers from the Walcheren expedition, and 
others of the remittents and intermittents of Canada, the West 
Indies and Italy ; it coincided, Dr. C. adds, with the descriptions 



90 CONTINUED FEVER. 

given by Audouard and others of the dingy, flushing, or leaden 
hue, which heralded the appearance of jaundice in cases of yellow 
fever. Dr. Arnott, of the Dundee Infirmary, mentions* black 
vomit as of very frequent occurrence in the cases which fell under 
his own notice. 

Sequelae. — These were, 1. A peculiar form of ophthalmitis, 
usually preceded by amaurotic symptoms. 2. Glandular swell- 
ings. 3. Boils and cutaneous eruptions. 4. Effusion into the 
knee-joint. 5. Swelled legs and ankles. 6. Pain in the feet, 
with and without swelling. 7. Paralysis of the deltoid, and cer- 
tain other, muscles. 8. Sloughing of parts. 

The occurrence, in a considerable number of cases, of a pecu- 
liar inflammatory affection of the eye, taking place during or after 
convalescence, was an interesting feature in the epidemic. The 
affection is described by Dr. Mackenzie under the name of post- 
febrile ophthalmitis. It appears to have occurred in greater pro- 
portion in Glasgow than in the cases treated in Edinburgh and 
elsewhere. In the Glasgow Eye Infirmary 36 cases occurred 
between the 8th of August and the 31st of October. It was 
characterized by amaurosis, or imperfect vision, affecting one or 
both eyes, and inflammatory action, extending from the retina to 
the other tunics of the eyeball. 

These attacks occurred at various periods from three to sixteen 
weeks after the accession of the fever. In several instances they 
happened about two weeks after convalescence from the relapse, 
but generally later. 

The same disorder, it would appear, occurred after the Dublin 
epidemic of 1826, and was described by Mr. Hewson, Dr. Reid, 
Dr. Jacob, and Mr. Wallace, confirming the views we have 
adopted of the identity of the epidemics. 

The treatment pursued with the greatest amount of success by 
Dr. Mackenzie was similar to that followed in cases of rheumatic 
and syphilitic iritis, and consisted principally of blood-letting, fol- 
lowed by calomel and opium, dilatation of the pupil with bella- 
donna, and counter-irritation. 

Anatomical Characters. — The post-mortem appearances 
were, 1. Abundance or even excess of bile, and a pervious state 
of the biliary ducts ; and 2. More or less congestion of organs, 
with frequently, extravasation of blood in various situations. 
These appearances are either identical with, or analogous to, 
what the majority of observers have noticed and described, as 
being those which are found in persons dying of yellow fever, 
and correspond remarkably with those observed by the French 

* [Letter on the present Epidemic of Dundee. Scottish and North of England 
Med. Gaz., vol. i. p. 129.] 



SYNOCHA OR INFLAMMATORY FEVER. 91 

commission at Gibraltar, in 182S ; particularly in reference to the 
peculiar condition of the liver, which Louis considers the ana- 
tomical character of yellow fever. 

State of the Blood. — That the blood really was in a dissolved 
state, was made perfectly manifest first, by the imperfect coagu- 
lation which it underwent when drawn from the veins of patients, 
a homogeneous spongy mass being formed, in place of a firm 
fibrinous clot, with a supernatant serosity ; second, by the ecchy- 
mosis which was uniformly observed to surround flea-bites or other 
slight injuries of the skin ; third, the frequent occurrence of purpu- 
rous spots ; fourth, the hemorrhages ; and fifth, the discoveries 
made by the microscope. " Professor Allen Thomson," Dr. Cor- 
mack says, " had the goodness to lend me his able assistance, in 
examining the blood of a number of my patients, by means of the 
microscopic. A few drops were taken from the thumbs on the 
same day (24th Oct.), of about a dozen persons, some of them in 
the pyrexial, and others in the apyrexial stage of the disorder; and 
it was found, that in all of them there were an unusual number of 
pus globules; and in some cases, in addition to this, all the glo- 
bules were found serrated and notched." 

One of the most interesting facts connected with the pathology, 
was the discovery of urea in the blood and serous fluid of the 
ventricles of the brain, in some of the patients affected with cere- 
bral derangement. The suspicion of this morbid condition was 
suggested to Dr. Henderson partly by the occurrence of convulsions 
in several cases in which there was no jaundice, and partly by a 
case in which symptoms of oppression and confusion of mind, 
accompanied with diminution of urine, was relieved by the oc- 
currence of diuresis after the exhibition of diuretics. In two cases 
which subsequently occurred, exhibiting indications of cerebral 
oppression, the state of the urine was attended to and the blood 
analyzed. In both cases the symptoms came on after the critical 
sweat ; and the urine was somewhat diminished in quantity, 
although not materially. In one case, the patient, after oppression, 
stupor, and a repetition of convulsive fits, died, and three drachms 
of serum from the ventricles of the brain, with some clots of blood 
from the head, were examined. Crystals of nitrate of urea were 
obtained in moderate abundance from the serum of the brain, and 
a very considerable quantity from the blood. In the other case, 
after somnolence, confusion, and languor, blood drawn from the 
arm yielded crystals of urea in small quantity. The character of 
the symptoms which succeed suppression of urine, and the ex- 
planation afforded of such cases by the detection of urea in the 
blood, have been long known to the profession. The possibility 
that a similar condition of the blood might be found to occur in 
other affections, and might afford the true explanation of sudden 



92 CONTINUED FEVER. 

death in diseases not expected to terminate thus, was suggested, 
we believe, by Dr. Christison. But we have here, for the first time, 
met with the realization of this conjecture, in the proof afforded 
by the observations of Dr. Henderson, that such an event may 
prove the immediate cause of death in cases of fever ; and that, 
too, even in cases where the obvious cause which might give rise 
to the presence of urea in the blood — namely, the suppression of 
urine — was absent. 

The facts elicited in these observations led to the further inves- 
tigation of the subject in Dr. Henderson's wards, by Mr. M. W. 
Taylor ; and in other two cases of fever — one of the epidemic, 
and one of typhus, both exhibiting the development of cerebral 
symptoms, with diminution of the urinary secretion — a circum- 
stance otherwise indicating a favourable prognosis — urea was de- 
tected in the blood. " The existence of urea in the blood," says 
Mr. Taylor, [Scottish Med. Gaz., p. 281,) "in other cases has been 
inferred from the occurrence of those symptoms of disorders of 
the nervous centres, which we know to be the consequence of its 
undue accumulation in the circulation. These phenomena have 
been observed in those cases in which, from some cause or other, 
the daily discharge of urine has undergone material diminution. 
This appears to take place chiefly at that critical period of the 
fever marked by copious sweating, at which the febrile symptoms 
begin to subside, or during the apyretic intervals between the 
attacks. Professor Henderson was the first who drew the atten- 
tion of the profession to the fact of the occasional presence of 
urea in the blood, at this stage of the fever, under the above-men- 
tioned circumstances." The inferences deduced by Dr. Henderson 
from these observations are of great practical importance, and 
may prove to be so in relation to the treatment of other fevers 
besides the one under consideration.* 

Prognosis. — The mortality was exceedingly small. By Dr. 
Alison it is stated not to have exceeded one in thirty. According 
to Dr. Craigie, the mortality in his wards was not more than 
one in sixty; by Dr. Kilgour it is stated to have been less than 
one in thirty-five in Aberdeen ; by Dr. Makenzie, to have been 
about three and a half per cent, in Glasgow; and from Dr. Ar- 
nott-s paper, it appears to have been only about one per cent, in 
the Dundee hospital. Dr. Cormack never saw any one, old or 
young, die of the ordinary form of the fever. A deep persistent, 
purple colour of the face appearing before, or immediately after 
the invasion of the disease, is a certain prognostic of danger 
according to the same authority. The states considered by Dr. 
Cormack as most apt to cause death, and therefore " to be anx- 

* [British and Foreign Medical Review, vol. xvii. p. 190.] 



SYNOCHA OR INFLAMMATORY FEVER. 93 

iously looked for, and if possible, promptly corrected/' are 1st. 
Congestion of the mucous membrane of the stomach and intes- 
tines, terminating in effusion of blood and subsequent destruction of 
large portions of this tissue. 2d. Congestion of one or more of the 
abdominal viscera, particularly of the liver and kidneys, disabling 
them from the performance of their secretive functions, thereby 
causing bodies to circulate with the blood, which ought to be se- 
parated from it, and which bodies we know act as poisons when 
not so eliminated from, or when directly introduced into the circu- 
lation. 3d. Debility and sinking, (p. 150.) With regard to the first 
state, in two or three of the cases recorded by Dr. Cormack, debility 
and sinking, followed by death, appear to have been occasioned 
by hemorrhage from the stomach or bowels ; and in those cases, 
exudation of dark-coloured blood, on and under the mucous mem- 
brane of the stomach and intestines, was found to a considerable 
extent upon examination after death. As to the second cause of 
death, it refers principally to the development of urea in the blood, 
as pointed out by Dr. Henderson ; but we have already sufficiently 
commented upon that point, and on the important relations which 
it bears to the treatment of this and, probably, of other fevers. 
In as far as the cause referred to (congestion of the abdominal 
viscera) is stated to have operated through the medium of the 
liver, we think there is every reason to believe, from the evidence 
before us, that the cases affected with jaundice were not more 
fatal than the cases not so affected. The debility and tendency 
to sinking were produced, we think, most commonly by the occur- 
rence of diarrhoea, or by the profuse sweating which formed the 
most frequent crisis of the fever. 

Nature. — The disease was undoubtedly contagious, though 
not to a great degree. Long-continued exposure to the poison, 
especially in persons who had to undergo great fatigue, generally 
was followed by an attack. In Dr. Cormack's hospital all the 
clinical clerks, hardly any of the nurses, laundry-women, or 
others coming in contact either with the patients or their clothes, 
have escaped; at one time there were eighteen nurses off duty 
from the fever; and of those who have recently been engaged for 
the first time, or of those who have hitherto escaped, one and 
another is from time to time being laid up. 

From the number of laundry-women that were attacked, it 
appears, that the clothes of our fever patients were especial re- 
positories and communicators of the morbid poison. An interest- 
ing fact, which may be introduced here, as it is probably to be 
explained by what has just been stated, was communicated to 
Dr. McCormack by Mr. Nicholson, from the island of Skye. 
He informed him, that two reapers, who had had the fever in 
Edinburgh, arrived in his neighbourhood after their return home 



94 CONTINUED FEVER. 

at the close of the harvest, when not a single case of the fever 
had been seen in the district. The mother of these persons, with 
whom they lived from the time of their arrival, was, in a few 
days, seized with the disease, and died. Other severe, and, in 
several instances, fatal cases occurred among the neighbours, who 
had waited upon her ; and the disease was then spreading to such 
an extent over the whole territory as greatly to alarm the inha- 
bitants. 

In the best districts of the new town of Edinburgh, there were 
a considerable number of isolated cases, but there was no instance 
of the disease propagating itself in these localities. 

It is a curious and interesting question, whether this form of 
fever proceeded from the same poison as the usual continued or 
typhus fever of Great Britain, or was truly a distinct disease. 

While Dr. Alison apparently inclines to the idea that this kind 
of fever originated from the same poison as the usual typhoid 
fever of Edinbugh, he points out with great discrimination the 
characters by which it was distinguished from the strictly typhoid 
cases. The peculiarities referred to by him are: 1. The duration 
of the cases, which was uniformly short ; the crisis occurring in 
most of them on the fifth or seventh day, very few being pro- 
tracted beyond the ninth. 2. The absence of the measly eruption 
of typhus. 3. The frequent occurrence of jaundice, accompanied 
by more or less fullness and tenderness in the hypochondrium, 
and vomiting of green bile, or brownish matters like hare-soup. 
4. The unusual degree of sickness and vomiting both in the jaun- 
diced cases, and in others. 5. The constant, or almost constant, 
occurrence of a relapse, generally taking place on the fourteenth 
day. 6. The termination of the disease, in the great majority of 
cases, by profuse critical sweats. 7. The frequency of severe 
muscular pains of a rheumatic character, during and after the 
sweatings, and particularly after the relapse. 8. The mortality, 
which was very small. The last peculiarity noticed by Dr. 
Alison, is the fact that in every pregnant woman affected with 
the fever who came under his care, abortion took place. 

Dr. Cormack states, that" when he commenced the observation 
and study of the present fever, and indeed, for a considerable time 
afterward, I regarded it as essentially and totally different from 
typhus ; but recent circumstances, and more matured weighing of 
evidence, have greatly modified this opinion." This though we 
think without sufficient evidence. Professor Henderson, as well 
as Dr. Craigie, advocate the opinion of the non-identity of the 
poison from which the two fevers originate. One of the most 
remarkable peculiarities, and the first which attracted the notice 
of Dr. Henderson, was the great frequency of the pulse in the 
new disease as compared with typhus, and the very different 
prognosis which was afforded by its frequency in the two diseases. 



SYNOCHA OR INFLAMMATORY FEVER. 95 

This comparison, in consequence of the short duration of the 
epidemic fever, was necessarily limited to the first five days ; and 
referring to examples in which it had been made, Dr. Henderson 
found the average frequency of the pulse in typhus on or before 
the fifth day, to be 100 per minute, while in the epidemic fever it 
was 123. He further observes, that according to common obser- 
vation, a great frequency of the pulse in typhus fever, more par- 
ticularly at an early stage, is deemed by practical men one of the 
most alarming symptoms next to those which proclaim immediate 
dissolution ; while in this epidemic it appeared to have no special 
indication. In the epidemic fever, the pulse was frequently as 
high as 140 or 145 on the second or third days, and the crisis 
took place as usual on the fifth, without any indication of danger, 
while in typhus, even a less degree of frequency was followed by 
a very large proportion of deaths. 

The next peculiarity noticed by Dr. Henderson is the mode of 
termination and rapidity of convalescence in the epidemic fever, 
as contrasted with typhus. 

The constant occurrence of one or more relapses is next pointed 
out by Dr. Henderson as one of the distinguishing features of this 
fever. 

In the fever under consideration, however, after the critical 
sweat of the fifth or seventh day, and a total though temporary 
remission, almost invariably a relapse, in the strict use of the word, 
that is to say a fresh attack of the fever took place, generally on 
the fourteenth day, ushered in by shivering, and running nearly 
the same course as the primary attack. With reference to the 
bearing of these upon the specific difference between typhus and 
the fever in question, Dr. Henderson remarks : — 

" That the difference in this respect between the two is a highly 
important one, I do not suppose that any one can doubt, and 
when I add that the cases of true typhus, which have occurred 
among the same class of the population, and at the same seasons, 
as the other disease, have presented no such tendency to relapse, 
or repetition of fever, as the latter does, it will appear, I conceive, 
that the liability to repetition cannot be esteemed other than a 
distinctive feature of the one disorder, and the absence of such a 
liability, a distinctive feature of the other, and that neither is 
dependent on accidental diversities in the epidemic constitution, 
either of the atmosphere or of the population, by which the effects 
of one and the same poison, might be presumed to be modified 
or altered/' 

Dr. Henderson cites a number of cases where the two forms 
of fever were exhibited in the same persons within a short period 
of time; some being affected with typhus soon after recovery from 
the epidemic, and some with the epidemic fever within a few weeks 
after their recovery from typhus. These facts, in the opinion of 



96 CONTINUED FEVER. 

the writer, appear, and with justice, to lead to the conclusion not 
only that the dissimilarity of the fevers cannot be referred to the 
modifying influences of constitution and season, but that they must 
have arisen from poisonous influences originally different in their 
nature and source. 

" The history of the progress of the epidemic fever, and that of 
the cases of typhus occurring during the same period, develops 
other facts of interest in relation to the point in question ; for, in 
the cases investigated by Dr. Henderson and others, the atttack 
of the epidemic fever was invariably traced to intercourse with 
persons affected with the same form of fever, and in cases of 
typhus to persons affected with typhus, while in no instance 
could any case be referred to the contagious influence of the 
other form of fever. In some of the cases referred to, the two 
forms of fever prevailed in the same locality but in different 
houses ; and in such instances the cases of the epidemic invariably 
came from that part of the locality where other cases of a similar 
kind prevailed, and those of typhus from the houses alone which 
the typhoid affection had visited, — facts which go very far to prove 
a difference in the kind of poison from which the two fevers origi- 
nated." * 

Dr. Cormack considers the bronzing of the countenance as an 
interesting point of resemblance between the yellow fever of hot 
countries and this epidemic, and aims at establishing an analogy, 
if not an identity between the two fevers. Dr. Craigie altogether 
rejects the idea of the fever bearing any analogy to yellow fever. 
" It is scarcely possible," he says, " with any consistency in noso- 
logy, or common obervation, to admit even the resemblance." 

History. — We have regarded this epidemic as similar to those 
described by Dr. Christison, as having prevailed in Edinburgh 
in 1817-20, and 1826-29, along with cases of typhus, from which 
it was steadily and uniformly distinguished as the five-day fever. 
In the mode of invasion, state of the pulse, the duration, the 
occasional jaundice, the critical sweats, the relapses, the occur- 
rence of rheumatic pains during convalescence, and other parti- 
culars, the cases were precisely alike.t Dr. Mackenzie says, 
" That it has at different times prevailed in Ireland is rendered 
highly probable from the fact that the course observed by some 
of the Irish epidemics corresponds exactly with that of the fever 
now present in Glasgow, while the complete identity of this fever, 
with that which prevailed in Dublin in 1826, is proved by the 
exact similarity of the affection of the eye, observed as a sequela 
in both instances. In Rutty's History of the Diseases of Dublin 
during forty years, we meet with several instances of an epidemic 

* [British and Foreign Medical Review, vol. xvii. p. 185.] 
f [On the Efficacy of Blood-letting in the present Epidemic Fever of Edin- 
burgh, by Benjamin Welsh, M.D., 1819.] 



SYNOCHA OR INFLAMMATORY FEVER. 97 

of the same character with that now under consideration. Thus 
in July, August, September, and October, 1739, a fever prevailed, 
which was < attended with an intense pain in the head. It ter- 
minated,' says he, < sometimes in four, for the most part in five or 
six days, sometimes in nine, and commonly in a critical sweat : it 
was far from being mortal. I was assured of seventy of the 
poorer sort at the same time in this fever, abandoned to the use 
of whey and God's good providence, who all recovered. The 
crisis, however, was very imperfect, for they were subject to 
relapses, even sometimes to the third time.' (p. 75.) He describes 
the same remittent fever as occurring also in 1740, 1745, 1764, 
and 1765 ; noticing as a circumstance of the disease in 1765, that 
the bowels were in some instances remarkably affected. There 
appears considerable resemblance between the present fever and 
that described by Dr. Stoker, as prevailing along with typhus 
gravior in Dublin in 1816. He speaks of it as a typhus mitior, 
its usual course being from three to nine days, generally termi- 
nating on or before the seventh day, but very apt to relapse on 
the third or fifth day from the favourable change. The Dublin 
epidemic of 1826, with which the present fever corresponds so 
exactly in its effects on the organs of vision, was also a remittent 
fever, as appears from the accounts published* of it by Dr. Reid 
and Dr. O'Brien. It was often attended by jaundice, and by 
pains in the bones ; its crisis happened generally about the seventh 
day ; the patients were very apt to relapse ; the number attacked 
was very great, but the mortality comparatively small— in all 
which particulars its analogy to the present Glasgow fever is 
borne out. Dr. O'Brien's Report might be applied to the disease 
now prevailing in this city, with scarcely any modification." — 
(Lond. Med. Gaz., Nov., 1843.) 

Dr. Spill an t has called attention to the resemblance of this 
epidemic, in all the important features, to that described by 
Hippocrates as occurring in the Island of Thasus, off the coast of 
Thrace. The same state of the spleen is mentioned. (Clifton's 
Ed. of Hippocrates on Air, &c, p. 62.) 

Treatment. — The treatment of this epidemic was exceedingly 
simple, and in the majority of cases seemed to have but little 
influence on the issue. All attempts to cut short the fever, to 
accelerate the crisis, or to prevent the relapses, seemed to have 
failed. The disorder ran its course, terminated at the usual 
period, and in the usual manner, equally well under one plan 
of treatment as another, or even of none. Blood-letting, both 
general and local, appears to have afforded great relief, in the 

* [Transactions of the Association of Fellows and Licentiates of the King and 
Queen's College of Physicians in Ireland, vol. v. pp. 266. 512. Dublin, 1828.J 
f [Lond. and Edin. Monthly Journal, Feb., 1844, p. 176.] 

7 



98 CONTINUED FEVER. 

experience of Dr. Alison and others, to the violent headache, and 
other uneasy feelings of the early stage of (he fever ; and could 
be had recourse to without those apprehensions of protracted 
weakness and exhaustion, which form the great obstacle to con- 
tend with in most cases of typhus fever. The tenderness in the 
epigastrium or hypochondriac regions, with indications of enlarge- 
ment of the spleen, appear to have yielded readily to the applica- 
tion of leeches. Dr. Cormack rather inclines to discountenance 
blood-letting, convinced that the latter symptoms give way with 
equal readiness after the diligent use of warm fomentations, and 
the former after the use of purgatives and cold applications 
to the head. He thinks that the headaches return soon after the 
blood-letting, although temporarily relieved, and appears to dread 
the debility which may ensue upon the use of such a remedy. 
Diaphoresis appears to have occurred spontaneously on the 
critical day, and to have been as profuse and as beneficial when 
no diaphoretics were used as when they were ; and although they 
were pretty constantly employed, they did not appear,, in any 
instance, to accelerate the crisis, but they afforded relief or satis- 
faction to the feelings of the patient. The administration of 
opium, and the external application of blisters or sinapisms to the 
epigastrium, were found very serviceable in allaying one of the 
most troublesome symptoms— the vomiting. In some instances 
Dr. Cormack tried creasote, in others hydrocyanic acid, for this 
symptom, and with marked success. The application of cold to 
the head for the purpose of allaying headache, and the use of cold 
or of hot, or tepid sponging of the surface of the body in allaying 
restlessness, were found by Dr. Cormack to be very useful and 
grateful to the patients. The administration of purgatives was 
found useful in mitigating the symptoms, and particularly in 
relieving the headaches. Croton oil was prized by Dr. Cormack, 
because, in spite of its activity, he did not find that it produced 
irritation ; but that, on the contrary, it appeared to soothe the 
gastric irritability and nervous excitement, and to leave the 
patients little exhausted, even after its free and frequent action. 
Mercurial purges appear to have been preferred by Dr. Craigie 
and others in the treatment of the jaundiced cases, but, after try- 
ing them extensively, Dr. Cormack concludes that the cases went 
on at least as well without them. The rheumatic pains with 
which the patients were affected during convalescence, do not 
appear to have been very amenable to treatment. From the use 
of colchicum, Dr. Cormack does not think his patients experienced 
any benefit. Astringents, chalk mixtures, acetate of lead and 
opium, acetate of lead and squills, &c., were found very service- 
able in the cases complicated with diarrhoea, dysentery, and 
bronchitis ; and tonics, with the occasional administration of 
stimulants, in the debility which, in many cases, accompanied and 



SYNOCHA OR INFLAMMATORY FEVER. \)\) 

followed the crisis. The chlorate of soda was used, but without 
any decided evidence of its advantages. The sulphate of quinine, 
both in small and large doses, frequently repeated, and other 
reputed anti-periodic remedies, were tried in a great many cases, 
with a view to prevent the occurrence of relapse; but, although 
Dr. Cormack conjectures that the former remedy modified or de- 
layed the relapse, none of them appeared to have any effect in 
the prevention of its occurrence.* 

In June, 1844, a vessel arrived from Liverpool at Philadelphia, 
with a number of Irish emigrants. There had been some sickness 
on board of the ship during her passage to this port. After her 
arrival, about fifteen of her passengers were admitted into the 
Philadelphia Hospital, suffering under a form of fever unlike any 
variety which has prevailed here for the last fifteen years— the 
period over which the writer's observations extend. The writer 
thought he recognized the form of fever just described, and the 
event proved the correctness of his supposition. The disease was 
precisely similar to the Edinburgh epidemic, except the sequelae ; 
and these might possibly have occurred, as the patients left the hos- 
pital as soon as the second convalescence was established. The 
disease, so far as the writer knows, did not extend ; and the only 
evidence of its contagion existed in two cases. Two sisters who 
had been residents of the city for several years, but whose brother 
had arrived out in the ship, and was taken with the fever at their 
house, were admitted into the hospital, suffering from decided 
attacks of the disorder. Several of the passengers were also 
inmates of the hospital, suffering from slight chills and sweatings, 
general uneasiness, some headache and vomiting, with prostration 
of strength, but finally recovered without experiencing a decided 
attack. Several cases from the same vessel were admitted into 
the Pennsylvania Hospital, under the charge of Dr. Pepper; 
who at first regarded them as cases of mild typhus, but subse- 
quently recognized their resemblance to the Scottish epidemic 
described by Alison, Cormack, Henderson, &c. None of the 
cases which fell under the writer's notice terminated fatally. 

A form of Inflammatory Fever, described by Dr. Felix Jac- 
quot,I as occurring amongst a portion of the garrison of Paris, 
prevailed in the hospital of Val de Grace, in the spring of 1844. 
After two or three days of illness, the sufferer entered the hos- 
pital. In nearly all there was fever from the commencement, 
though in a few the initial chill occurred, whilst in others there 
were slight chills subsequently. The febrile action was severe 
and continued, with, in some instances, daily exacerbations 

[* B. & F. Med. Rev., vol. xviii. f Gaz - Med -> tom - xii -> 1845 '1 



100 CONTINUED FEVER. 

towards evening, occasionally preceded by slight, short chills/ 
In nearly all there was slight, continuous frontal cephalalgia; 
epistaxis occurred in a few cases ; there was sometimes cough, 
with sibilant rhonchus ; in a small number there were vomiting 
and nausea ; thirst and anorexia in all ; and in nearly all diar- 
rhoea, or diarrhoea alternating with constipation. The stupid 
expression invariably observed in typhoid fever was absent; the 
patients talked freely, willingly, and for some time ; the sleep, 
though bad, was not troubled with dreams. The duration of an 
attack was from four to twelve days. The epidemic commenced 
about the latter part of April, and terminated in the beginning of 
June.] 



C. SYNOCHUS, [OR TYPHOID FEVER. 

Syn. Typhus Mitior, Cullen ; Febris Mucosa, F. Mesenterica, Baglivi ; Morbus 
Mucosus, Roederer and Wagler ; Fievre Adi.no Miningee, Pinel ; Fievre Typhoide, Fr. ; 
Dothinenterie, Bretonneau ; Mucous F. ; Pituitous F.; Common Continued F. j Slow 
Nervous F.; Abdominal Typhus; &c] 

This is probably the most frequent of all types and forms of 
continued fever. It is essentially characterized by the disease 
commencing as synocha and terminating as typhus. There are 
scarcely any cases of primary continued fever, which do not pre- 
sent an inflammatory stage of longer or shorter duration, and of 
more or less violence at the commencement ; so that, perhaps, all 
continued fevers not falling under the purely inflammatory type, 
might be considered as synochus. But in nosological arrange- 
ments, as well as in practice, the term is usually, and in reference 
to treatment conveniently, restricted to such primary fevers as 
begin with a distinctly marked inflammatory stage like synocha, 
lasting for at least a few days, and not giving way to adynamic 
or typhoid symptoms till the beginning of the second week at 
soonest. Such was the general nature of the epidemic fever which 
raged in the United Kingdom from 1817 till six or eight years 
ago ; and such too seems to have been the Febris Bellica of the 
Continent, which broke out in the large towns of Germany and 
other continental countries of Europe in 1814, subsequently to the 
French war ; and of which, indeed, the British epidemic was pro- 
bably a propagation. Under the same head may be classed most 
of the fevers described by English authors of the last century, 
under the name of nervous fever. The most remarkable ex- 
amples of it which have perhaps been ever seen, occurred in the 
British epidemics of 1817-20 and 1826-9. For the inflammatory 
stage was often so well marked, that it was impossible to tell for 
some days whether the disease was to terminate as synocha, or 
pass on to the typhoid stage of synochus ; while, on the other 



SYNOCHUS OR TYPHOID FEVER. 101 

hand, the typhoid characters of the advanced stage were often in 
those very cases so well developed, that no one, seeing the disease 
for the first time at this period, would have known from the symp- 
toms that it had ever been anything else than true typhus. In 
later years the inflammatory stage has become much less promi- 
nent ; and in the generality of cases, at least in Edinburgh, as well 
as in other great towns, it has at present almost disappeared, and 
given place to typhoid symptoms from a very early period of 
attack. 

Symptoms. — In describing synochus it seems unnecessary to 
enter into particulars. The details of the typhoid stage are exactly 
the same with those which will presently be given under the head 
of typhus. Those of the inflammatory stage have been already 
related at sufficient length under that of synocha. In synochus, 
as in synocha, the fever is sometimes simple, but much more fre- 
quently complicated, as in the latter, with local inflammation in 
the early stage. Later in the disease, when typhoid symptoms 
are formed, local inflammations and local congestions frequently 
appear as in typhus, and more frequently than these secondary 
disorders are observed to show themselves in the early stage. 
Yet, even in the latter stage, secondary affections are sometimes 
absent, so that we have a pure, uncomplicated, primary synochus 
from first to last. Cases of this nature were clearly observed 
during the British epidemics above referred to. The most common 
secondary affections in this, as in the inflammatory form of con- 
tinued fever, are, in Britain at all events, inflammatory diseases of 
the lungs— pleurisy, pneumonia, but especially catarrh, often pass- 
ing into bronchitis. 

The passage of synocha into typhus usually takes place, as 
already remarked, in the course of the second week. It is indi- 
cated by the pulse opening up as it were, becoming fuller, more 
compressible, though still often equally jarring, and falling at the 
same time somewhat in frequency. The tongue also acquires a 
brown dry streak down the centre ; the heat is less pungent, while 
the skin is equally dry ; but, in particular, the muscular exhaus- 
tion increases greatly ; the senses, from being irritable, become 
more obtuse than natural, especially the sight and hearing ; the 
integuments, from presenting a bright red flush, acquire a dingy 
reddish-brown tint, of the nature of congestive redness; and there 
is a marked tendency to doze, sometimes intermingled with slight 
muttering delirium. These changes gradually lead on to the state 
of true typhus in its characteristic form, which will now be de- 
scribed. 

[The reader is referred to the section on the Typhoid Fever of 
this country, by the editor, for further details of this variety of 
continued fever.] 



102 CONTINUED FEVER. 



D. TYPHUS. 



[Syn. Synochus Putris; Pestis Bellied; Typhus Gravior, Cull en ; F. pestilentialis 
Europce ; Typhus Contagiosus Exanthematicus, Hildenbrand ; Fievre adynamique atax- 
ique, Pinel ; Typhus Contagieux, Fievre d'Hbpital, Fr. ; JDer Ansteckende Typhus, Das 
Ansteckendefieber , Das ExanthematischeNervenfieber, Kriegspest, Germ.; Tifo Contagioso, 
Febbre Putrida, Ital. ; Febbre Petechiale, Rossi ; Jail Fever, Putrid F. ; Spotted F. ; Ex- 
anthematic Typhus; &c. &c] 

As Synocha passes by insensible shades into Synochus, so the 
latter passes insensibly into Typhus. The early stage of inflam- 
matory symptoms may be observed in different cases to be shorter 
and shorter in duration, and more and more intermingled with 
nervous depression or adynamia, till at length we have a fever, 
in which the inflammatory reaction is never characteristic, and is 
followed at an early period even of the second week by the same 
phenomena which constitute the latter stage of synochus. 

The term Typhus has gradually acquired of late a rather vague 
signification. In consequence of passing into unprofessional lan- 
guage, it has come gradually to signify, in familiar speech, Infec- 
tious Fever ; and in this signification it is used even by many 
physicians. In correct nosographical language it should compre- 
hend only those fevers where the characters of adynamia, or ner- 
vous depression, present themselves as the predominant feature of 
the disease from first to last. But in practice the term has been 
extended from this very restricted meaning, so as to embrace that 
far more numerous class of cases where such characters show 
themselves before the close of the first week, and where the earlier 
stage of pure inflammatory action, although present, is not well 
marked. In this sense typhus is scarcely less important than 
synochus in point of frequency. In many epidemics it is the ruling 
form ; and, for a few years past, in Britain generally, and espe- 
cially in Edinburgh, 4t has constituted almost the sole prevailing 
type. 

Definition. — Typhus may be defined, a fever characterized 
by a compressible, rather frequent pulse, little increase of the 
animal temperature, extreme languor and debility, and much 
disturbance of the mental functions. Some, following the 
example of Cullen, indicate as another character its origin in 
infection ; which, however, is by no means peculiar to this alone 
among continued fevers ; neither is there a certainty that it is an 
invariable character even of typhus. The most remarkable cir- 
cumstances in typhus are the great exhaustion of the muscular 
strength, and the torpor of the mental functions, often mingled 
with delirium. The latter character is undoubtedly the founda- 
tion of its name, which is derived from iv$o$ } stupor. 



TYPHUS. 103 

Under this definition, and therefore under the specific name of 
typhus, may be arranged a very great variety of epidemic fevers, 
which have been variously denominated, by the writers of the 
last century especially, Low Fever, Low Nervous Fever, Jail 
Fever, Camp Fever, Hospital Fever, Malignant Fever, and the 
like. These will be all found, on referring to the descriptions of 
authors, to arrange themselves under the head of fever marked 
by the predominance of nervous exhaustion, as shown by feeble- 
ness of the pulse, prostration of the strength, and torpor of the 
functions of the mind. 

[History. — Typhus Fever has probably existed from the re- 
motest antiquity. The epidemic which occurred at Athens dur- 
ing the Peloponnesian war was probably typhus. It was the 
typhus camp fever, which prevailed in the Carthagenian army, 
at the siege of Syracuse, an excellent description of which may 
be found in the writings of Diodorus, the historian ; and other 
instances are mentioned by Livy, all of which appeared in the 
midst of large armies. Aetius gives an account of an exan- 
thematous fever, (Tetrab. ii. sect. 1, cap. 12,) which we have 
every reason to infer was typhus. Subsequently the Arabian 
physicians, and Jacques Desparts, one of the commentators of 
Avicenna, designate it very clearly. Actuarius, and still later 
Cardano, of Milan, Nicholas Massa, ( De Febre Pestilenti, 
1540,) and Georges Agricola, [Be Pesle,\ib.,l554,) make frequent 
mention of this disorder in their writings. But it was not generally 
known, or accurately described until the XVIth century; since that 
period extensive epidemics of typhus have prevailed throughout 
Europe. That of 1528, which carried off 21,000 men from the 
French army, then occupying Italy, was one of the first ; and the 
description of it by Frascator has always excited much atten- 
tion. Afterwards came the epidemic of 1552, which decimated 
the army of Charles V at the siege of Metz, (Math. Unzer. 
Catoptron Loimides S. de lue pest ef era, lib. 3, Halae, 1615.) 
In 1566, it broke out in the army of Maximilian II, then collected 
in Hungary to oppose the Turks, spread over a great part of 
Europe, and was known under the name of Febris Hungarica. 
Since then it has appeared during all of the European wars, and at 
periods of general suffering and famine. The plague of Misnia 
in 1676, that of Denmark in 1613, and 1652, and that of Leyden 
in 1669, were all examples of contagious typhus. Ozanam, in his 
History of Epidemics, mentions more than two hundred epidemics 
of typhus. It has appeared frequently in Ireland, and occasionally 
in England and Scotland. During the wars of the French Revo- 
lution it followed in the train of the vast armies then collected, 
spread through Germany, Switzerland, Italy, and France, com- 
mitting the most destructive ravages. The "Spotted Fever," 
which prevailed in New England between 1807 and 1816, is 



104 CONTINUED FEVER. 

generally regarded by writers, as true typhus fever. Dr. Ger- 
hard thinks,* that some of the epidemics which prevailed in the 
Middle States, between the years 1812 and 1820, were of typhus 
fever. The epidemic fever which devastated Italy in 1816-17, 
was, as regards symptoms, identical with the British typhus. (Pal- 
loni, Febbre Tifoide, &c, p. 150.)] 

Symptoms. — It has been seen above that inflammatory fever, 
in general, commences abruptly ; and such also is the case with 
characteristic instances of synochus, where the inflammatory 
type and stage are well-marked. Typhus, on the contrary, and 
in common with it those cases of synochus which approach the 
typhoid form, in general begin gradually. Epidemics, indeed, 
have been described, where the patient is at once struck down 
by typhoid prostration ; and in all epidemics, instances of the 
kind occasionally present themselves to the physician's notice. 
[The period of incubation, or that which elapses from infection 
until the manifestation of the disease, ranges from a few hours 
to five or six weeks. Boudin (Essai de Geographic Medicate), 
relates an undoubted instance where this stage lasted for a month. 
Sometimes patients are enabled to indicate the exact moment that 
they are attacked. J. Frank mentions the case of his brother, 
who believed that he knew the instant the contagion entered his 
system. Drs. Marsh, Tweedie, and Gregory give examples 
of instantaneous affection after exposure to the contagion. Dr. 
Alison knew a physician to be attacked at the bedside of a 
fever patient. Dr. Gerhard records two instances, where an 
attack followed exposure almost immediately. An attendant in 
the hospital was employed to shave a man, who died shortly 
after ; during the operation he inhaled his breath, which had a 
nauseous, disagreeable odour ; one hour afterwards he was 
seized with the disorder, and had it severely. Another, in rais- 
ing up a typhus patient about dying, felt the acid perspira- 
tion of the moribund upon his skin : he was seized with typhus 
almost immediately afterwards. Hildenbrand, however, denies 
that an individual can ascertain the time the infection takes 
place. He says that he paid particular attention to the sensa- 
tions which occurred in his own person while sitting at the bed- 
side of typhus fever patients, in order to ascertain whether he 
could perceive any peculiar feeling arising from the contagion ; 
and, although he contracted the disease, and knew the patient 
who communicated it to him, he was wholly unable to distin- 
guish any peculiar impression depending on the contagious 
poison. In a large majority of cases the accession of typhus 
fever is gradual] But much more generally the disease begins 
with slight languor, trivial headache, disturbed sleep, deficient 

* [Am. Journ. Med. Sciences, 1836.] 



TYPHUS. 105 

appetite and inaptitude for mental or bodily exertion. In a day 
or two, or sometimes after an interval of several days, an attack 
of chilliness or rigor first convinces the patient that a serious ill- 
ness is impending, and ushers in the unequivocal symptoms of 
fever. The pulse is now rather frequent, ranging between 90 and 
100, seldom higher except in the young or in irritable habits, oc- 
casionally natural, or even under the healthy standard ; and it is 
generally full, sometimes, however, small, commonly jarring at 
the extremity of its expansion, and always easily compressible. 
The tongue is white, often with red points from enlargement of 
the papillae ; and this state is attended with complete loss of ap- 
petite, as well as urgent thirst. The strength is greatly reduced, 
and there is a peculiar sense of exhaustion, felt even while the 
patient is in bed and at rest. The breathing is somewhat accele- 
rated, short, with occasional sighing. The skin is rather hot, 
but seldom in such a degree as to occasion the desire for cold air, 
or to affect decidedly the hand of the physician. The bowels 
are commonly constipated ; the urine not high-coloured, or loaded 
on cooling, with sediment ; the breath fetid, and in some mea- 
sure peculiar ; the cutaneous secretion either unaffected, or at 
times assuming the form of irregular sweats, partial, of short 
duration, and unattended with any abatement of the fever. The 
countenance is generally dingy, flushed, languid and oppressed ; 
the eyes somewhat injected, watery and heavy, with unsteadiness 
of vision, but seldom much intolerance of light ; the whole ex- 
pression is peculiar, so that by it alone an experienced physician 
may commonly recognize the disease. [The patient is averse to 
any exertion, answers questions tardily, protrudes his tongue 
slowly, and frequently is incapable of withdrawing it. There is a 
dull, stupid expression of the countenance, together with a charac- 
teristic suffusion of the face and eyes. The hue of the face is a 
dull, livid red, extending over its whole surface, corresponding 
with a strong, dark injection of the conjunctivae. This congestion 
extends to the mucous membrane of the nasal fossae, pharynx, 
larynx, and even to the bronchi, as exhibited by the difficult 
deglutition, coryza, oppression, and cough.] There is almost al- 
ways more or less headache, though it is often very trivial ; also 
commonly ringing or buzzing in the ears, with an undefinable 
sense of obscurity or distance of sounds, unconnected, however, 
with deafness ; the ideas are confused, and the patient complains 
much of giddiness when he sits or stands. General pains, espe- 
cially in the back, and febrile weariness and restlessness, though 
often present, are seldom so distressing as in synocha, and the 
early stages of synochus. Sleep is disturbed, and the patient 
imagines he gets none. Sickness is frequent, also vomiting, and 
still more a sense of fullness in the epigastrium ; yet these symp- 
toms are far from invariable, as some pretend. [Many writers 



106 CONTINUED FEVER. 

speak of epistaxis, as a common and important symptom oc- 
curring about the third or fourth day, and about this time the 
peculiar eruption appears. 

In the generality of cases, the symptoms here described con- 
tinue with little variation, except in degree, till towards the close 
of the first, or more frequently the beginning of the second week. 
In a few, little change takes place even then, except that some 
degree of stupor is observed, in connection with dryness and 
brownness of the tongue, listlessness, unwillingness to be dis- 
turbed, and progressive anaemia ; and recovery commences in 
eleven, fourteen, or seventeen days. In others, on the contrary, 
the characters of aggravated typhus form even about the middle 
of the first week ; but such cases are rare. 

Most generally at the beginning of the second, or close of the first 
week, the tongue becomes brown, dry, often chapped, and the teeth 
covered with dark sordes ; the pulse is either more soft or more 
jarring, yet compressible, and usually about 100 in frequency ; the 
skin continues dry and not particularly hot, becomes often rough, 
harsh and dingy, and frequently presents eruptions, which will 
be described under the head of the secondary affections. [The 
perspiration has a peculiar odour, mentioned by most writers, and 
regarded as characteristic. Dr. Pickels says, that upon entering 
the room of a typhus patient, the presence of the disease was 
indicated, previous to any examination, by this peculiar fetor 
from the skin. Dr. Do ane informed Dr. B artlett, that many of the 
emigrant patients with typhus fever, at the New York quarantine 
Hospital, gave out an odour which he described as sour, dirty, 
and offensive. Dr. Gerhard says, that the odour is pungent, 
ammoniacal and offensive, especially in fat, plethoric subjects. It 
has been said to resemble that from a mouse.] The evacuations 
are dark and fetid ; the heat of the surface is little increased, but 
irregularly distributed, especially in the extremities, which are 
apt to become cold ; the temperature is seldom much above the 
natural standard, often below, and occasionally, it is said, so low 
as 92° F.; there is little complaint, except of weakness and want 
of sleep ; sickness and vomiting, if previously present, disappear; 
the eyes are -more suffused and heavy, the complexion darker 
and less flushed, and the expression that of disturbed oppressive 
sleep. The muscular debility and sense of exhaustion are very 
great, sometimes excessive, and accompanied at times with a 
tendency to fainting ; and in a few cases the disease is brought to 
an abrupt termination by fatal syncope induced towards the end, 
or even sometimes the beginning of the second week, by some 
imprudent effort of the patient to sit up in bed, or rise to stool. 
There is also, commonly, wandering of the mind, marked by 
slight incoherent muttering and occasional incorrect answers, 
sometimes by more active delirium and constant incoherent 



TYPHUS. 



107 



rambling, and at times by loud talking and tendency to roam 
about ; [or, the patient dreams without being asleep (typho- 
mania), is tormented by a single idea, which is generally an 
internal impression, and disregards all external objects.] In 
some the tendency to get out of bed and wander up and down 
is inveterate, so that constant attention is required to prevent 
accidents. [Deafness is frequent at this stage of the disorder ; 
complete vision is impaired ; and sense and taste lost. The pa- 
tient appears to be in a state resembling somnambulism ; he lies 
perfectly insensible to all around, and, if aroused, answers that he 
is quite well.] 

It is generally observed that the symptoms undergo an exacer- 
bation during the evening and early part of the night, and a 
remission in the morning and early part of the forenoon. The 
double exacerbation, conceived by some to occur at midday as 
well as midnight, is either imaginary and founded on precon- 
ceived theory, or must be present only in special epidemics, and 
has been rarely witnessed for many years past. 

[We insert the following table, showing the maximum fre- 
quency of the pulse, in 181 cases of eruptive typhus, admitted 
into the Glasgow Fever Hospital, from May 1st, to November 
1st, 1839. 



Table of the Maximum Frequency of the Pulse in 181 Cases 


of Eruptive Typhus. 


Males. 


, Females. 


Maximum frequency 


Number of Cases. 


Maximum frequency 


Number of Cases. 


of Pulse. 




of Pulse. 




86 


5 


96 


12 


96 


20 


98 


1 


100 


8 


100 


3 


104 


4 


104 


5 


106 


3 


108 


23 


108 


15 


110 


1 


110 


1 


112 


3 


112 


4 


116 


3 


116 


4 


120 


17 


118 


1 


124 


7 


120 


18 


130 


10 


124 


5 


134 


2 


128 


1 


140 


4 


130 


1 








90 




91=181 


Average maximum of pulse in Males =107-5. 


" « Females= 114-1. 


" " Males and Females= 110-8. 



108 CONTINUED FEVER. 

The five cases in which the pulse is marked 86, were admitted 
on the seventh, ninth, eleventh, fourteenth, and twenty-first days 
of the disease, so that it is probable that partial convalescence 
had commenced at the time the pulse was noted. 

Every case below twenty years of age has been excluded, be- 
cause the maximum of the pulse varies more from childhood to 
adolescence than during any other similar period of life ; and 
those who died have also been excluded, as the comparison be- 
tween the pulse and the recovery would not be Uniform in the 
two diseases, and as the average maximum of the pulse of those 
cases which terminated fatally was greater than that of those Who 
recovered. 

This table shows, that in 181 cases of eruptive typhus occurring 
in adults, the maximum frequency of the pulse was not below 
96, except in five cases; that in about three-fourths it was 108, 
and upwards ; and that the average maximum of the whole was 
110-8.] 

As the disease advances [or, about the third week], the pulse 
becomes more feeble, the tongue darker, more dry and often 
retracted, the complexion more dingy, the prostration excessive 
and often attended with tremor of the hands and starting of the 
tendons at the wrists, the stupor deeper and less interrupted by 
delirium, the evacuations involuntary, or the fecal discharges in- 
voluntary, with retention of urine and distension of the bladder. 
Where the event is unfavourable, death is preceded for one or two 
days by increased frequency and a jarring state of the pulse, 
hurried, interrupted breathing, hippocratic expression of the coun- 
tenance, much injection of the conjunctivae, increased subsultus 
of the tendons, twitches of the muscles of the face, singultus and 
deep coma. Where, on the contrary, recovery is to take place, 
the tongue becomes moist and cleaner on the edge, the pulse 
more full and less jarring, the delirium milder and more broken 
by natural sleep, the stupor less profound, so that the patient is 
more easily roused, the expression that of drowsiness rather than 
of oppression ; and frequently these favourable signs are attended 
with increased sensibility to the natural appetites, so that drink is 
asked for, and sometimes food also. These changes are very 
generally followed by progressive amelioration; which, however, 
is always gradual and slow. 

Fatal cases, where not resulting from sudden syncope early in 
the disease, most generally terminate between the eleventh and 
seventeenth days, very seldom sooner, and not often later, except 
through the intervention of secondary diseases. Amendment, or 
what is usually termed the " turn," or crisis of typhus, also com- 
monly occurs between the eleventh and seventeenth days, most 
generally about the fourteenth. But sometimes the disease goes 



TYPHUS. 109 

on much longer, and with very little alteration in the nature or 
degree of the symptoms ; and instances at times occur of mild 
typhus continuing unabated for six weeks. 

[The duration of typhus is irregular, varying with each epidemic 
and in individuals ; it ranges from five to thirty days. It generally 
runs its course in from one to six weeks. A great degree of un- 
certainty exists in the evidence obtained from hospitals, from the 
unsatisfactory answers received from patients, as to the period 
when the disease commenced, as well as from the discrepancy 
which arises in the different methods of calculation adopted by 
physicians. Some regard the disease as terminated on the com- 
mencement of the convalescent stage ; while others include the 
whole period of the patient's residence in the hospital as its dura- 
tion. Another difficulty arises from their not classifying patients 
according to their ages, and the degree of severity of the disease. 
The disorder is of less duration in young persons than in adults, 
and in mild than severe cases. Dr. Stoker states that of four 
hundred and seventy-one cases, mostly mild, nearly three-fourths 
terminated on or before the seventh day. Dr. Pickels found it 
rarely to exceed the eleventh or thirteenth day, and in many cases 
to be much shorter ; and Dr. E. Percival says fatal cases terminated 
between the eleventh and seventeenth days. Dr. Bkacken asserts, 
that in the epidemic of 1817, 1818, and 1819, the greatest number 
of deaths took place on the ninth day ; and then, successively, on 
the tenth, twelfth, eleventh, seventh and eighth. These writers do 
not, however, inform us in what manner they estimated the dura- 
tion of the disease. Dr. Mateer, of Belfast, makes the average 
duration of typhus much greater; he found of 11,209 patients 
treated during a series of nearly twenty years in the Belfast hos- 
pital, that the average period, during which the patients remained 
in the hospital, was about twenty-two days, and that they had, 
on an average, been ill about seven days before being brought in. 
This would give a mean duration of twenty -nine days. The 
termination fixed on was not the crisis or commencement of con- 
valescence, but the complete restoration of health. Had the first 
period been taken, the fourteenth day would be the time at which 
the point of intensity was reached. According to Dr. Alex- 
ander P. Stewart, the mean duration of typhus fever at Glas- 
gow, calculated from the results of many thousand cases, during 
successive years, was twenty-one days.* Dr. Henderson says, 
that the average day on which convalescence commenced at the 
Royal Infirmary of Edinburgh, in 1838, 1839, was the thirteenth. 
The average period at which death took place, calculated from 
forty-three cases, was between the twelfth and thirteenth days.t 
Dr. Arthur Thompson states, that the average duration of 2630 

* [Ed. Med. and Surg. Journ., Oct., 1840. f lb., Oct., 1839.] 



110 CONTINUED FEVER. 

cases was twenty^seven days ; and this calculation was made from 
cases described and enumerated in the works and papers of Drs. 
Bateman, S. Smith, Latham, and Craigie.]* 

Authors have described a variety of phenomena which may 
present themselves at the time of crisis, and which appear to be 
connected somehow with the favourable change, such as sponta- 
neous diarrhoea, bleeding from the nose, a profuse discharge of 
highly loaded urine, and, above all, perspiration. [Dr. Bartels 
has detailed three cases in which the appearance of sores upon 
the tongue was regarded as critical in the course of typhus fever, 
no mercury having been given.]t There is no question that such 
" critical evacuations" do at times occur in typhus. But their 
frequency has been much overrated. Probably here, as in many 
other respects, important differences present themselves in differ- 
ent epidemics ; and of late, assuredly, it has been rare that any 
increased natural discharge, or any preternatural evacuation, has 
been observed to accompany the crisis of fever. 

[Many writers assert that the commencement of convalescence 
in typhus is distinctly marked, that it is preceded by certain pheno- 
mena of a decided character ; a sort of struggle between the suffer- 
ing economy and the diseased action. Dr. Stewart, of Glasgow, 
says : " All that I insist upon is the frequent, I may say, the com- 
mon occurrence of a perceptible crisis, or what is vulgarly termed 
a turn, in typhus. I think I may appeal to the experience of every 
physician, and more especially of every resident clerk in a fever 
hospital, for they have more constant opportunities of observation, 
whether they have not often been struck at seeing, during their 
morning visit, the glassy eye, the haggard features, the low, mut- 
tering delirium, the stupor approaching to coma, the tremor, the 
subsultus, the carphology, the rapid, thready, tremulous, and in- 
termittent pulse, of the previous evening ; the formidable array 
of symptoms, in short, which seemed to indicate a speedy and 
fatal termination, exchanged for the clear eye, the intelligent coun- 
tenance, the steady hand, the comparatively slow and firm pulse, 
and thereturning appetite of approaching convalescence. To such 
cases as these we might almost apply the Scripture phrase, ( At 
such an hour, the fever left him ;' and if the crisis is not very fre- 
quently so marked, we can, in the great majority of cases, point 
with precision at least to the day on which amendment began to 
take place.";}: Hildenbrand insists that the patient is generally 
able to determine the degree of relief afforded by these critical 
evacuations ; or, that he, at least, can distinguish those of a salu- 
tary nature. He moreover asserts that the relief is immediate 

* [Edinburgh Med. and Surg. Journ., July, 1838.] 

f [Allgem. Med. Centr. Zeitung, 11 and 14 Jan., 1843.] 

i [Edinburgh Med. and Surg. Journal, Oct., 1840.] 



TYPHUS. 



Ill 



and striking. The urine, he conceives, deserves less consideration 
than any other critical evacuation.] 

Favourable cases show a decided tendency to terminate upon 
what are called critical days. This fact has been generally denied 
in modern times ; but close observation has shown that the ancient 
physicians were correct in admitting the doctrine of critical days. 
[Decisive crisis, when the disease is mild and regular, generally 
takes place, Hildenbrand states, about the fourteenth day, and 
very rarely on the seventh. Dr. Mateer says, " the point, com- 
monly termed crisis, occurs at some fixed time. In one hundred 
consecutive cases, carefully noted for this purpose, it was found, 
on a mean calculation, that the fourteenth day was that on which 
this crisis took place.*] Such is the result of the only extended 
series of observations recently made, those of Dr. Welsh in tha 
Edinburgh epidemic of 1819. The critical days are 3, 5, 7, 9, 11, 
14, 17, 20; the non-critical are the intermediate days; but 4 and 
6 are considered secondarily critical. The following table, con- 
structed from 630 cases, where the commencement and termination 
of fever could be fixed with tolerable precision, certainly presents 
a remarkable correspondence with the ancient doctrine. 



Days. 


Days. 


Crit. 


Non-crit. 


Cases. 


Crit. 


Non-crit. 


Cases. 


3 

4* 

5 

6# 

7 

9 
11 


4# 

6* 

8 

10 

12 
13 


6 
18 
80 
34 
129 
26 
80 
17 
69 
80 
15 


14 
17 
20 


15 
16 

18 
19 

21 
22 
23 


63 

10 

11 

34 

2 

4 



15 
3 




Hence of 690 cases, crisis took place in 470 on critical days, in 52 
on the subsidiary critical days, and in only 10S on the days which 
are considered non-critical. It must *be observed that these data 
are founded on cases of the three types of fever taken promiscu- 
ously, and at a time when synocha and synochus were common. 
[Another and more recent observer, Dr. Davidson, has published 
his researches on this subject, which are unfavourable to the doc- 
trine of critical days. 

* [Ed. Med. and Surg. Journ., Oct., 1840.] 



112 

Table 



CONTINUED FEVER. 



the Bay of the Disease on which complete Convalescence was esta- 
blished in 181 Cases of Eruptive Typhus. 



Males. 


Females. 


Day of Disease. 


Number of Cases. 


Day of Disease. 


Number of Cases. 


12th 


1 


13th 


2 


13 


4 


14 


7 


14 


2 


15 


11 


15 


9 


16 


3 


16 


9 


17 


9 


17 


9 


18 


10 


18 


6 


19 


6 


19 


7 


20 


10 


20 


3 


21 


3 


21 


10 


22 


5 


22 


8 


23 


2 


23 


2 


24 


3 


24 


6 


25 


1 


25 


2 


27 


4 


26 


4 


28 


1 


27 


4 


29 


3 


28 


1 


30 


2 


29 


3 


32 


1 






34 


4 






36 


1 






44 


1 






54 


2 




90 




91=181 tot. 


Average convalescence i 


n Males =19-7 days* 


. a a 


Females=21-3 days. 


a (c 


days in Males and Females=20-5. 



This table shows that only one case of typhus was convales- 
cent on the 12th and six on the 13th day of the disease, out of 
181; and that the average convalescence of the whole was 20*5 
days.] 

The blood in typhus puts on a different appearance from what 
is observed iu synocha. It is not bright, but on the contrary very 
dark, flows sluggishly from the vein, coagulates loosely, and sel- 
dom shows any appearance of a buffy coat. These characters 
become more and more marked as the disease advances: and in 
the latter stages of bad cases the blood coagulates so loosely, as 
to be tremulous, brittle, and almost to resemble ill-made currant 
jelly. It also alters materially its chemical constitution, becoming 

* [Dr. Henderson states that he has seen instances of convalescence on the 
seventh and eighth days, in which the eruption had existed; but it is not men- 
tioned at what stage of convalescence the calculation was made, and what were 
the ages of the patients. — Edin. Med, and Surg. Journal, Oct. 1839, p. 430.] 



SECONDARY AFFECTIONS. 1 13 

much poorer in all its solid contents, but especially in colouring 
matter and saline materials, t'he analytic researches of Dr. 
Clanny show that the salts and hsematosin are often reduced to 
two-thirds of the healthy proportion. 

[Dr. Gerhard describes the blood in the epidemic of Philadelphia 
in 1836, as being at a very early period, dark, without the buffy 
coat, and offering a large, but soft and dark-coloured coagulum. 
At a more advanced stage, it presented in some patients the dis- 
solved appearance, described by various authors as characteristic 
of typhus or putrid fevers. Dr. O'Brien says " that in those in- 
stances where blood was taken in the advanced period of the 
disease, he always found its texture broken down and dissolved, 
changing rapidly into a greenish, watery fluid, with little coagulum, 
indicating great dissolution of the animal fluids." Huxham has de- 
scribed the altered state of the blood in typhus. Analytical details 
will be given in the section on typhoid fever.] 



II. SECONDARY AFFECTIONS IN CONTINUED FEVER. 

Such are the symptoms, more or less essential, of the three great 
forms of primary continued fever. They are subject to great va- 
riety, owing to the various degrees in which the inflammatory and 
typhoid characters are combined. But they are also subject to still 
greater variations from the concurrence of secondary affections. It 
is in fact rare to observe a case of fever, whether typhoid or inflam- 
matory, but more especially the former, run through its entire 
course without some incidental or secondary disorder making its 
appearance. 

[Dr. Arthur Thompson gives the following table of the com- 
plications of fever from cases related by Drs. Smith, Tweedie, 
Alison and Craigie, and it shows that the complicated varieties 
are much more numerous than the simple or uncomplicated : 

Simple Fever, 374 

Fever with Cerebral Complications, 375 

Thoracic do 264 

Abdominal do 180 

Mixed do 308 

1501] 

Cases of pure unmixed primary fever do not occur quite often 
enough, as formerly stated, to satisfy every attentive observer 
that such a thing as primary fever has real existence ; but still 
cases of complication are infinitely more common ; and they are 
proportionally most common where the fever lasts for some time, 
and where a disposition is manifested towards the typhoid form. 
They are proved to be secondary, and not essential to the fever, 
8 



114 CONTINUED FEVER. 

because they present a great variety in their seat and nature 5 
because they are sometimes all absent ; because they very seldom 
make their appearance till the fever has subsisted for several 
days ; and because they both appear and disappear without the 
course of the fever being thereby materially altered in any essen- 
tial symptom. They seem to depend for their origin on certain 
local infirmities of constitution, or on the body having been 
exposed to some of the ordinary causes of local disorders about 
the period of invasion of the fever ; and the direct pathological 
state which induces them is, in all probability, congestion of 
vessels in the part attacked— a state which exists more or less 
throughout the internal organs generally, and which is developed 
by co-operating influences into more positive local disease. In 
very many cases, however, it is impossible to point out satisfac- 
torily the co-operating cause ; and for the most part, much is left 
to be ascribed to obscure peculiarities of season, terrestrial locality, 
or epidemic constitution. These peculiarities are in some circum- 
stances observed to be so comprehensive in their operation, as to 
impart a. peculiar character to an entire epidemic of fever. And 
from such occurrences it is — from certain local disorders occurring 
with great frequency on certain times and in certain places— that 
many physicians have been impressed with the notion that the 
fever was not primary in its nature, but in reality secondary to 
the local affection. 

There is scarcely any end to the number of local disorders 
which may occur incidentally during fever. Most of them par- 
take of the nature of local inflammation. The secondary symp- 
toms to which they give rise may be conveniently arranged 
according as the seat of disease is in the head, throat, chest, 
abdomen, or skin. 

1. Affections of the Head. — The incidental affections 
referable to the head are chiefly congestion in the brain or its 
membranes, meningitis, and a convulsive affection allied to epi- 
lepsy. 

In all cases of typhus and in the advanced stage of synochus, it 
seems probable that there is a tendency to a congested state of 
vessels in the whole internal organs, especially, perhaps, in those 
of a membranous structure, and among the rest in the brain and 
its membranes. This appears probable from the state of all the 
membranous surfaces visible from without; such as the skin, the 
conjunctiva?, the Schneiderian membrane, and the lining mem- 
brane of the mouth and throat, which are all of them often seen 
to be dark and unusually vascular. It is scarcely correct to 
consider this state as secondary, or at least an incidental affection. 
It is probably the consequence of the depressed state of the 
nervous system, which has been already often insisted on as one 



SECONDARY AFFECTIONS, 115 

of the essential circumstances of primary fever. It lies in the 
ordinary course of events; it is secondary in one sense, in so far 
as it is consecutive ; but it is not incidental. In some cases, how- 
ever, congestion of the brain is so great in degree and so prominent 
in its symptoms, as to become a highly important local affection; 
and in this sense it deserves mention in the present place, while 
passing from the essential symptoms of primary fever to the more 
purely secondary disorders. The symptoms of inordinate con- 
gestion in the brain and cerebral membranes, are dingy redness 
and heat of the face, as well as heat over the integuments of the 
head, dark and minute injection of the conjunctivae of the eyes, 
an extreme degree of stupor, aggravated muttering delirium, great 
feebleness and increased frequency of the pulse, irregular distri- 
bution of temperature in the extremities, a dark, dry tongue, 
which cannot be protruded — all the symptoms, in short, of the 
most highly developed state of typhus. This is the most frequent 
cause or manner of death from continued fever in the British 
Islands, as well as in many other countries. On some occasions 
the symptoms of cerebral congestion show themselves at so early 
a period in the disease, and so generally, as to impart a peculiar 
character to the epidemic, and to have led some to describe such 
a fever under the distinguishing name of Congestive Typhus. 
But it is probable that all cases of true typhus are attended more 
or less with this affection. 

The frequent occurrence of cerebral congestion, and the sirni 
larity of its symptoms and morbid appearances to those of certain 
forms of cerebral inflammation, have led some pathologists, with 
Dr. Clutterbuce at their head, to imagine that fever is essentially 
a Meningitis. This is undoubtedly a mistake, and it was clearly 
a happy conception, for which medicine is mainly indebted to the 
late Dr. Armstrong, to characterize the local derangement as 
congestion. True meningitis is a very rare affection, as secondary 
or incidental to continued fever. There are at least few apparent 
cases of it, which may not be as correctly referred by the symp- 
toms to congestion. And, indeed, where the symptoms are cha- 
racteristic, and the diagnosis during life is shown to have been 
justified by unequivocal appearances after death, it generally 
admits of question, whether the disease ever truly was continued 
fever, or anything else than a primary local inflammation. It is 
a strong proof of the reasonableness of this question, that une- 
quivocal meningitis is exceedingly rare, where alone there can be 
no doubt of the fever being primary, in cases of fever clearly 
referable to infection. In one shape meningitis has been thought 
by some to be not uncommon in fever. In persons at or beyond 
the middle term of life, who have been long addicted to intem- 
perance, the symptoms often put on a very aggravated character 
from an early period, being compounded, as it were, of those of 



116 CONTINUED EEVEK. 

congestive typhus and delirium tremens. The delirium comes on 
earlier than usual, and is intense; there are great tremor of the 
hands, a highly Hushed state of the countenance, and much injec- 
tion of the conjunctives; coma supervenes speedily; and inter- 
current convulsions are not uncommon. In such cases, which 
for the most part terminate fatally, unusual injection of vessels is 
found in the membranes of the brain, and likewise an unusual 
amount of effusion of serosity in the sub-arachnoid cellular tissue, 
as well as in the ventricles and base of the brain. These phe- 
nomena, however, present nothing which may not be referred 
with equal or greater propriety to congestion ; they are the symp- 
toms and anatomical characters of congestion in its most aggra- 
vated degree. Meningitis, it is true, is indicated by symptoms 
closely similar ; and, when fatal in the early stage, may- present 
no other appearance after death but congestion or serous effusion. 
Still this fact will not entitle the pathologist to assume that con- 
gestion becomes inflammation in the cases in question. There is 
nothing in the phenomena during life to warrant such a doctrine; 
the effects of remedies in particular furnish no corroboration ; and 
anatomical evidence is wanting, so long as there are not found, 
what is undoubtedly very rarely found in true continued fever, 
occasionally instances of effusion of lymph, or at least capillary 
vascularity, without gorging of the larger vessels and sinuses. 

It has been justly observed, that in some cases of bad conges- 
tive typhus, occurring especially in drunkards, intercurrent con- 
vulsions are apt to present themselves. But a Convulsive affec- 
tion, allied to epilepsy in its characters, also occurs at times, 
independently of the constitution of intemperance, and even of 
any marked degree of congestion in the brain. It is a rare inci- 
dental disorder. It is perhaps always fatal. It appears most 
generally towards the middle or close of the second week, but 
sometimes so early as before the termination of the first. It is 
occasionally preceded by drowsiness and an unusual degree of 
headache for a day or two ; but more commonly the patient is 
seized on a sudden with coma, convulsions of the trunk, extremi- 
ties, and face, copious perspiration, hurried convulsive breathing, 
a rapid, excessively jarring, but easily compressible pulse ; and 
death ensues in the course of one, two, or at most six hours. No 
appearance is ever found within the head to serve as an explana- 
tion of this remarkable incidental disorder ; but the writer may 
mention, that in every case which has come under his notice since 
the publication 'of Dr. Bright's hospital reports, the kidneys have 
been found more or less affected by the granular degeneration, 
which he was the first to indicate with precision. It must be 
farther observed, that, where this organic derangement of the 
kidneys subsists, death sometimes takes place from convulsions, 
preceded for a few days by an affection, not unlike mild typhus ; 



SECONDARY AFFECTIONS. 117 

and that such cases are accordingly apt to be confounded with 
continued fever. 

2. Affections of the Throat. — The incidental affections re- 
ferable to the throat are chiefly cynunche tonsillaris, aphthous 
ulceration of the throat and mouth, cynanche laryngea, and cy- 
nanche parotidasa. These disorders, with the exception of cy- 
nanche parotidsea, appear most frequently during the harsh irregu- 
lar weather which precedes in this climate the approach of winter, 
and follows its departure, more especially during the prevalence 
of northerly winds. They are often the source of much annoy- 
ance to the patient ; but they are seldom in themselves the source 
of danger — the whole of them, not excepting even cynanche laryn- 
gea, having a tendency to become resolved in the progress of the 
fever, and being for the most part amenable to treatment. It 
seems unnecessary to dwell on the special symptoms of these locaL 
disorders. Cynanche parotidsa, so far from being any sign of 
danger, is not unfrequently a concomitant of the crisis or turn of 
fever ; and, from a remote period, has, therefore, been commonly 
held by nosoiogists to be an auspicious sign in circumstances other- 
wise favourable. It is not, however, so invariably auspicious as 
many imagine : it is often, too, the source of great distress: and, 
in severe fever, it is prone to run on to suppuration, especially in 
unsound constitutions. 

3. Affections of the Chest. — Next to congestion of the brain 
and its membranes, there is no class of incidental diseases more 
important than those referable to the chest. In the British Islands, 
and above all, perhaps, in Edinburgh, they are the most frequent 
of all secondary affections ; so that, amidst the tendency of modern 
pathologists to the doctrines of Non-essentialism, it is rather re- 
markable that no one has taken up with the chest as his hobby, 
for seating the local cause of fever. 

Catarrh, indicated by cough, at first dry, afterwards with clear 
mucous sputa, and by mucous murmur attending respiration, is 
an exceedingly common accompaniment : and sometimes, at par- 
ticular seasons, scarcely a single case occurs in hospital practice 
without more or less of it. It often occurs very early in the fever, 
sooner perhaps than any other incidental affection ; and hence the 
patient is sometimes at first deceived, and his attendant puzzled, 
as to the real nature of his attack. But for the most part it is 
secondary in point of importance ; frequently it disappears in a 
few da}'s under mild treatment ; seldom does it influence mate- 
rially the course of the fever ; and very rarely is any risk run from 
its usual termination is cases of idiopathic catarrh — mucous gorg- 
ing of the bronchial tubes. This incidental disorder must be dis- 
tinguished from one which considerably resembles it in the symp- 
toms, but which arises from a different cause and at a different 



118 



CONTINUED FEVEB. 



period of fever. In the advanced stage of typhus or synochus, 
especially where the cerebral oppression is considerable, patients 
are very subject to a short, hacking cough, the exertion for which 
in their exhausted condition causes much general distress and un- 
easiness, and may even induce them to complain of pain when 
questioned on the subject. As there is usually in this state short 
hurried breathing, the result of mere debility, and sometimes also 
a little clear mucous expectoration, the symptoms may lead to a 
suspicion of catarrh or obscure pneumonia being present ; and the 
inexperienced are apt to commit this error in diagnosis, and to 
treat the affection unnecessarily and injuriously as of the nature 
of inflammation. From pneumonia it may be distinguished by 
the patient being able to take a full breath without uneasiness, 
by the clearness of the chest everywhere on percussion, and by 
the stethoscope indicating merely a slight, dry mucous murmur at 
the extremity of inspiration chiefly. From proper catarrh it is 
principally distinguished by the period of its occurrence in the 
course of the fever, and by the inconsiderable expectoration which 
attends the cough, even where it has lasted several days. This 
affection passes off promptly after the fever takes a favourable 
turn, and without the aid of any express remedies. The rationale 
of it seems to be, that the pulmonary circulation partakes of the 
congestive disorder of the capillary circulation at large ; and that 
the cough arises from the irritation of the injected mucous mem- 
brane, or obstruction of the passage of blood through the vascular 
system of the air-cells. It may be conveniently distinguished by 
the name of Congestive Catarrh. In the latter stage of fatal 
cases of typhus or synochus, the affection becomes accompanied 
With serous effusion, especially in the depending portion of the 
lungs, where it is seen after death, and where during life it is in- 
dicated by the stethoseopic sign of crepitation. 

Pneumonia and pleurisy are on the whole rare local affections 
in the course of fever; yet they are sometimes unequivocally 
developed, and for the most part under the co-operation of ob- 
vious exposures. They are most frequent in the latter stage of 
all the three forms of fever ; and in that case they are apt to con- 
tinue after the primary fever subsides, and to run their own proper 
course. When they occur at an early stage of the fever again, 
they are in general subdued with little difficulty, if discovered in 
time ; and then the fever may continue its course uncomplicated. 
Both pleurisy and pneumonia are sometimes met with in the 
early stage of convalescence, as the result of undue exposure to 
atmospherical vicissitudes. It may be also observed of either, 
but especially of pleurisy, that where it appears to originate 
during fever or convalescence, the inflammatory disorder is some- 
times found, on careful inquiry, to have existed in an obscure 
form for some time before the invasion of the fever. It is unne* 



SECONDARY AFFECTIONS. J 19 

cessary to detail the particular symptoms of these two diseases 
when secondary to fever, because they present no peculiarities in 
the febrile state. The only circumstance requiring consideration 
is, that the torpor of the senses and mental faculties may render 
the patient unaware of his condition, or incapable of complaining 
of it ; and that the practitioner, wherever either is suspected to 
exist, must attend more to the sputa, to the sounds elicited by 
percussion, and to the indications of the stethoscope, than to any 
other information, such as may be obtained by questions. There 
appear to be some epidemics of fever, where pneumonic inflam- 
mation is exceedingly prevalent as a secondary disease, insomuch 
as almost to form the epidemic character of the fever, and to be a 
common immediate cause of death. No epidemic of this kind 
has been observed of late years, especially since the improvements 
introduced into the diagnosis of pneumonia by the discoveries ot 
Laennec ; and the chief observations on the subject were made a 
considerable number of years ago. It is not improbable that the 
supposed pneumonia was nothing else than the congestive affec- 
tion of the lungs, described under the head of Catarrh. 

[This complication is very common in many parts of the United 
States, especially during the winter months ; it may, indeed, be 
said to be endemic in certain localities. It is generally known as 
Pneumo7iia Typhoides. This form constituted the great winter 
epidemic of 1812-13; and was regarded, by the best authorities, 
as distinct from the Spotted Fever, before alluded to (p. 103), and 
which prevailed in the northern districts of the Eastern States.]* 

4. Affections of the Abdomen. — The secondary affections of 
the abdomen which occur during continued fever, are some of 
them objects of extraordinary interest in the present day ; to all, 
on account of their great frequency ; and to noUa few, as sup- 
plying, in their opinion, evidence against the non-essentiality of 
fever. There is scarcely any organ in the abdomen which is not 
at times affected during fever in such a way as to constitute an 
incidental or secondary affection. But the most important dis- 
orders are an obscure affection of the stomach, of the nature of 
inflammation or irritation — swelling and subsequent ulceration of 
the muciparous glands of the intestines, constituting the dothin- 
enteritis of late pathologists — and derangement of the hepatic 
organs, attended with the external symptoms of jaundice. 

A common accompaniment of continued fever is an obscure 
disorder of the stomach, allied to Gastritis. In this country we 
frequently meet with cases where the patient is affected, particu- 
larly towards the close of the first and beginning of the second 
week, with severe sickness, frequent vomiting, tenderness in the 

* [See Williams & Clymer on Diseases of the Respiratory Organs. Philadel- 
phia, 1845, pp. 177—182.] 



120 CONTINUED FEVER. 

epigastrium, or positive pain increased by pressure. These symp- 
toms, which are more frequent in other countries, and especially 
in France, have been assumed to depend on inflammation in the 
mucous membrane of the stomach ; while others ascribe them 
with greater probability to mere irritation only, connected, it is, 
Hkely, with a congested state of the organ, or to a mere functional 
disturbance depending on depressed action of the brain. Accord- 
ing to a late fashionable doctrine, that of Broussais, who has 
still his followers in many places, this local affection is a real 
inflammation, always present, more or less, and not merely an 
accompaniment, but likewise, in connection with a similar dis- 
order of the intestines, the essential cause of all continued fevers. 
There are now comparatively few who adhere to this doctrine in 
its full extent ; in Britain its admirers were never distinguished 
either by their number or by their eminence ; and certainly it 
would have been odd, had many converts been found among 
those who have faithfully observed on the great scale the phe- 
nomena of the British epidemic fevers. The symptoms in ques- 
tion are frequently absent altogether ; and when present, if they 
are to be regarded as evidence of inflammation, all that need be 
said is, that, for so formidable a disease as inflammation of the 
mucous membrane of the stomach, the symptoms are wonderfully 
easy to subdue, since they seldom resist a few leeches or a blister. 
At times, however, the affection is severe, the nausea being 
excessive, the vomiting frequent and constantly excited by drinks 
or medicine, and the tenderness and tension very distressing. It 
is not easy to pronounce what the nature of this affection may 
be in such cases ; but, as happens in milder instances of the like 
kind, it is for the most part easily subdued by gentle antiphlo- 
gistics ; and, except the relief given to local suffering, no manifest 
change takes place in the phenomena of the fever. Such are the 
results of British experience on this much agitated topic. 

In other instances of fever it is supposed that the mucous mem- 
brane of the intestines may be similarly affected, giving rise to a 
secondary Enteritis. In some cases, even in this country, there 
are observed in the progress of fever distension and firmness of 
the abdomen, tenderness or positive pain, with an anxious coun- 
tenance, and either constipation or diarrhoea. But abroad, and 
above all, it appears, in France, such cases are very frequent, 
and for the most part severe. Two affections have been indicated, 
one consisting probably of irritation, possibly of incipient and mild 
inflammation, of the intestinal mucous membrane generally ; the 
other, a far more formidable disorder, consisting of inflammation, 
suppuration, and eventually ulceration of the solitary and con- 
glomerate glands of the intestines, in concurrence generally with 
enlargement and sometimes suppuration of the mesenteric glands. 
These two affections, along with the supposed variety of gastritis 
just described, are thought by many to be invariably present in 



SECONDARY AFFECTIONS. 121 

continued fever, as it shows itself in France, and are believed 
conjunctly to be the true cause of fever. The latter intestinal 
disease, in consequence of the recent researches of Bretonneau 
and Louis, is believed by many to be invariable in typhus ; and 
the anatomical lesions connected with it are believed to constitute 
the essential cause of anatomical character of typhoid fever. 
Both affections are undoubtedly met with in the fever of this 
country. Much more frequently, however, both are absent ; and 
the common rule is, that a case of fever passes through all stages 
of the disease, without any symptom whatever referable to a 
disorder in the bowels, except some flatulent distension, vague 
uneasiness rather than absolute pain, and constipation. But in 
particular diarrhoea, the most invariable symptom, both of the 
milder and of the more severe disorder, is comparatively a rare 
incident, at all events far less common than the very opposite 
condition. 

It is not easy to distinguish the two affections of the bowels by 
their symptoms ; for in both of them there are fullness and tension 
of the abdomen; frequently, though not always, tenderness; some- 
times griping pain ; and very generally a frequent, watery, yellow 
diarrhoea. That such secondary symptoms must in general arise 
in the continued fevers of this country from nothing more than 
irritation, or at most a low state of incipient inflammation of the 
intestinal mucous membrane, would seem sufficiently obvious 
from the simple fact that they are, for the most part, very easily 
checked, or that, where they do continue for some time unsubdued, 
they seldom add much to the exhaustion occasioned by the fever, 
and eventually disappear of themselves, either by degrees before 
the fever ceases, or more promptly after a crisis takes place. They 
are certainly, in by much the greater proportion of cases, regarded 
by British practitioners without alarm ; and not unfrequently a 
mild yellowish diarrhoea seems even to keep down the force of 
febrile action in cases of synochus ushered in by a sharp inflam- 
matory stage, and cannot be altogether arrested without apparent 
injury from aggravation of the general fever. 

The occurrence of Dothinenteritis is a very different incident. 
This very interesting disease, which, as formerly stated, seems to 
have been first observed in 1762 by Roederer and Wagler, and 
again in 1813 by Petit and Serres, has of late years attracted 
much attention, especially in France, since the investigations of 
Bretonneau into its anatomical characters, and the elaborate and 
precise inquiries of M. Louis into its relations to fever. The latter 
eminent pathologist concludes, as the result of his researches, that 
it is never wanting in true typhus, and is the local cause of that 
variety of fever — an opinion in which he is followed by many.* 

* [We have already shown (p. 54), that nowhere does Dr. Louis maintain 
such causation.] 



122 CONTINUED FEVER. 

There can be no question, however, either that dothinenteritis is 
merely an occasional, incidental, or secondary affection during 
fever ; or that it is a wholly different disease from that to which 
the name of typhus has been long appropriated in this and other 
countries. For the invariable experience of British practitioners 
extensively conversant with the features of typhus is, that enlarge- 
ment of the glands of Peyer and Brunner, situated in the inner 
membrane of the intestines, is a rare, and in many parts of Britain, 
a very rare occurrence. M. Louis, as formerly mentioned, is now 
inclined to think that the two diseases are essentially different. 
Such may well be the case. All that British pathologists can 
reasonably hold out for is, that the dothinenteritic affection shall 
be admitted to present itself at times as secondary to typhus, since 
in Britain it occurs only occasionally during epidemics of typhus, 
and the cases where it is seen, originate, as clearly as other cases 
of typhus, in infection. The term typhus, or " typhoid affection/' 
ought not to be appropriated, as M. Louis desires, to this local 
affection — to this newly-discovered disease— which is far more 
frequently absent than present in what used to be called typhus. 
No one, however, will deny that the local disease, secondary in 
one circumstance, may become primary in another, and even pre- 
sent itself as such in the epidemic form. In short, let the name 
originally proposed by Bretonneau* be retained as simply de- 
scribing its anatomical character (809^, a pimple, and htspov, the 
intestine), and it may be granted that, like catarrh, pneumon,a, 
and other inflammatory local disorders, dothinenteritis may both 
occur as a primary disease, and also as secondary to typhoid fever. 
As a farther illustration of the secondary character of this affec- 
tion in Britain, it may be observed, that instances of it are not 
only far more uncommon here than in France, but likewise that 
their frequency seems to differ much in different quarters of this 
kingdom. From the accounts lately published of epidemic fever 
in London, Manchester, and Edinburgh, for example, the disease 
would appear to be decidedly most frequent in London, and least 
frequent in Edinburgh. In Edinburgh it is unquestionably a rare 
concomitant of fever. In the infirmary it has been constantly and 
diligently looked for during the last sixteen years in several epi- 
demics ; yet it is found only often enough to make the pathologist 
acquainted with its phenomena, and keep him in mind of its 
existence. On one occasion only, during the latter months of 1829 r 
when a dysenteric tendency showed itself to an unusual degree in 
the population generally, and, above all, in the hospital, has it 
been observed to constitute an appreciable proportion of the fever 
cases. 

[• Dothinenterle, and not Dothinenteritis, was the name originally proposed by 
Dr. Bretonneau, (p. 54)]. 



SECONDARY AFFECTIONS. 123 

[On this point, Dr. Watson says : " Since attention has been 
drawn to the subject, the patches of glands, and the whole tract 
of mucous membrane, from the stomach to the rectum, have been 
diligently explored ; and the result seems to be that, at certain 
times and places (in other words, in certain epidemics), the ulcer- 
ation of the inner surface of the intestines is far less common than 
in others. It was comparatively rare in an epidemic of which 
I witnessed some part in Edinburgh. Then I came to London, 
and, for several years, I never saw a body opened after death by 
continued fever without finding ulcers in the intestines. Still, in 
my own experience, such ulcers have been vastly more often # 
present than absent." [Lectures on Practice of Physic. ,)] 

The symptoms of dothinenteritis are sometimes obscure ; and, 
if the affection be not fully formed before the fever has advanced 
far, the typhoid oppression renders them very indistinct, so that 
no farther indications are perceptible than the equivocal signs, 
flatulent distension, uneasiness on pressure, and yellow diarrhoea. 
When its external characters are well-developed, there are, in 
addition, general tenderness or pain, felt especially on pressure in 
the right iliac region, short hurried breathing, commonly a red, 
dry, chapped tongue, and sometimes vomiting — an important sign 
when it occurs late in typhus. It is commonly attended at an 
early period, and almost always sooner or later, with a profound 
state of typhoid oppression. If we are to grant to M. Louis and 
his countrymen, that it may occur as a primary idiopathic disease,* 
we must also concede, that its symptomatic fever is peculiarly 
typhoid, undistinguishable by any essential characters from the 
true primary typhus of British pathologists. Its course is very 
frequently unfavourable, and death seems in general owing, not 
as in dysentery, to exhaustion, but to gradual aggravation of the 
typhoid state. In a few instances, however, it terminates in in- 
testinal perforation, indicated by sudden acute pain in the right 
iliac region, spreading, burning pain over the abdomen, sickness 
and vomiting, hippocratic expression, dreadful anxiety and ex- 
treme exhaustion, followed by death in the course of from eighteen 
to thirty-six hours. A remarkable proof of the profound nature 
of the typhoid coma which attends the disease is, that sometimes 
even perforation and consequent peritoneal inflammation take 
place, as shown by dissection, without any particular signs of the 
event having been observed during life. In favourable cases 
recovery is commonly slow, provided the symptoms of the local 
affection be well-marked, for the patient has to pass through the 
slow process of restoration of the healthy state of the intestines 
from suppuration or ulceration. Nevertheless it is seldom, at 
least in this country, that he does not eventually overcome the 
disease, should he not sink under the typhoid depression of the 

* [A concession never asked by Dr. Louis, and most of his countrymen.] 



124 CONTINUED FEVER. 

nervous system in the early stage. [See chapter on Typhoid Fever 
by the Editor.] 

The only other important abdominal affection of a secondary 
nature which requires mention, is disorder of the hepatic system, 
accompanied with jaundice. This is a rare complication, occur- 
ring chiefly in the autumn months, and principally in those 
epidemics where the inflammatory type is prevalent. Yet it is 
important, because cases where it occurs commonly prove fatal. 
The exact nature of the affection is not apparent. The symptoms 
are, rapidly formed jaundice, sickness with frequent vomiting, but 
without particular uneasiness in the region of the liver, extreme 
prostration of strength, much tendency to coma at an early period 
of the fever, speedy sinking of the pulse, and, in general, bilious 
stools. The symptoms show themselves in the course of the first 
week. If they do not begin to abate in two or three days, death 
occurs in a few days more, under a. state of extreme exhaustion 
and deep coma. Should the yellowness of the skin, however, 
begin to diminish, the other secondary symptoms soon subside 
also, and the fever runs its usual course. Some have imagined 
this affection to be allied in nature to the yellow fever of hot 
countries, but with what justice it is not very easy to say. 

[In the account of the Epidemic Fever in Scotland, in 1843, it 
was mentioned that the cerebral disorder which had been referred 
to jaundice, was, in reality, due to the presence of urea in the 
blood (p. 92). How far this may be true in other fevers, it is 
impossible to say. In a case of typhus exhibiting analogous ce- 
rebral symptoms, with diminution of the urinary secretion, urea 
was detected in the blood by Mr. M. W. Taylor. {Scottish Med. 
Gaz., vol. i. p. 289. Ed. 1843.)] 

5. Affections of the Skin. — The affections of the slrin, which 
occur as secondary to continued fever, are of much importance, 
not merely on account of the danger attending some of them, but 
likewise because they often singularly aid the physician in form- 
ing his prognosis. The chief affections requiring mention are, the 
various forms of petechias, an eruption analogous to measles, vibi- 
ces, miliaria, sloughing, and erysipelas. 

Petechias of one kind or another are so common in some epi- 
demics of fever, that it is rare to find a case without more or less 
of them. They often escape notice, it is true, because they are 
not expressly looked for in the quarters where they may most 
generally be found. At the same time there is no ground for the 
notion lately entertained by some, that in real infectious fever, or, 
as stated by others, in true typhus, petechise are never entirely 
wanting. This notion has clearly arisen from partial observation, 
confined to particular epidemics. Extended observation in many 
epidemics leads to the conclusion, that in continued fever of ail 



SECONDARY AFFECTIONS. 125 

types petechias are not essential, but secondary. Three kinds of 
eruptions have often been comprised under the generic term pete- 
chias:— 1. One, which is exceedingly rare, but which is occasion- 
ally remarked in the advanced stage of bad synochus or typhus 
for a short time before death, consists of small, pale brown, lenti- 
cular spots, without any elevation or roughness of the skin, and 
much resembling freckles. 2. Another, which is very common in 
some epidemics, and especially where the early stage of fever 
presents the inflammatory character, forms small, dark, reddish- 
black, roundish, accurately circumscribed, and often closely crowded 
spots, without elevation of the skin, and much resembling flea- 
bites. Their resemblance to fleabites is such, that on the one 
hand, the latter are often mistaken for petechias ; while, on the 
other hand, some physicians will insist that real petechias are 
nothing else but fleabites. The two appearances, however, can- 
not be mistaken by a careful observer, because the petechial spot 
does not present the little dark point in the centre, which may be 
invariably seen in the fleabite, either with the naked eye, or with 
the help of a common magnifier. Sometimes the petechias are 
few in number, and readily escape notice ; in other instances, on 
the contrary, they are excessively crowded. Their usual seat is 
upon the breast, shoulders, forearms, and legs ; but they may be 
seen also on all other parts of the body except the face. They 
generally make their appearance towards the close of the first or 
beginning of the second week, and certainly not on a specific day, 
like the eruptions of the febrile exanthemata, as some have main- 
tained. They are observed to occur chiefly in severe cases, but, 
from frequent observation in the epidemics of Edinburgh, they 
do not necessarily indicate danger ; on the contrary, the cases in 
which they appear have proved rarely fatal. The appearance is 
owing to a thin stratum of extravasation on the surface of the 
true skin, and appears connected with increased force of the cir- 
culating system, being most characteristic where reaction is high. 
This form of petechial eruption has become rare (1838) for a few 
years past. 3. The third variety presents more or less numerous 
spots, of a paler, rather lake-red or rose-red tint, irregular in shape, 
not distinctly circumscribed, but rather diffuse round the edge, 
with sufficient elevation of the skin to impart a sense of rough- 
ness to the finger, when drawn over a part where they are nume- 
rous. They present some resemblance to measles ; and at times 
are so like that eruption, that the other symptoms must be looked 
to for the diagnosis. They present the same variety in number 
with the dark circumscribed petechias; they are usually most 
abundant over the chest, shoulders, forearms, legs, loins, flanks, 
and abdomen ; and they are not unfrequently found loosely scat- 
tered round the loins, flanks, and upper part of the belly, although 
not visible anywhere else, so that, if not sought for, they may 



126 / CONTINUES FEVER. 

escape notice altogether. Different accounts have been given of 
the usual time of the appearance of this form of petechia?. In the 
epidemics of Edinburgh it appears about the seventh day, for the 
most part, sometimes a day or two later or earlier. Elsewhere 
it is stated to occur very regularly on the fourth day ; at leasts 
some have described a measly-like eruption, which appears to 
come under the present head, and which is said to break out so 
regularly on a particular day, and that day the fourth of the 
fever, as to have warranted in some measure the conclusion, that 
the disease was a variety of continued fever, assuming the gene- 
ral habitudes of the eruptive fevers. The diffuse pale petechias 
occur almost entirely in epidemics and cases of the typhoid type. 
It is, perhaps, invariably associated with a severe attack ; and 
cases where it appears often prove fatal. According to M. Louis 
it is an invariable concomitant of the intestinal disease, which he 
considers the anatomical character of true typhus. But, in this 
country at least, it is also very often observed where there is no 
such local disorder.* 

It appears, then, that the occurrence of petechial eruptions in 
continued fever has led to a considerable variety of speculations 
as to their nature and the nature of the disease in which they are 
presented. Some have been contented with arranging the cases 
under the general head of continued fever, but with the special 
title of petechial fever ; others hold this petechial fever to be a 
specific fever, originating in a specific infection, and capable of 
producing, or of being produced by itself alone : others maintain 
that, as the eruption appeared to them to break out very regularly 
on a special day, the disease is specific, and one of the febrile 
exanthemata, among which accordingly they are inclined to 
arrange it; and, lastly, by many French pathologists one variety, 
the diffuse pale petechia, is thought peculiar to dothinenteritis.f 
In the opinion of the writer, founded on the observation of several 
epidemics of fever, varying much in type, none of these doctrines 
is tenable except the first, which assigns a specific name, for the 
sake of convenience, to a mere variety of common continued 
fever. And petechias can be correctly regarded in no other light 
than as an incidental circumstance in fever, neither confined, nor 
essential, to any one species of it. 

In the preceding statement a considerable variety of eruptions 
have been comprehended under the general designation of pete- 

* [These spots are not petechias at all. Dr. C. has here confounded a cutane- 
ous efflorescence with a cutaneous or subcutaneous hemorrhage.] 

-j- [Andral, Chomel, Piorry, Rostan, Cruveilhier, Bouillaud, &c, admit that the 
lenticular rose spots occur, though but rarely, in other diseases. Chomel, more* 
over, insists that it is the number of these papulae which give them value in the 
diagnosis of typhoid fever. They are to be found in mild, as well as severe cases 
of typhoid fever. Dr. Louis says, that they are as rare in other acute diseases as 
they are common in this. (See section on Typhoid Fever.)] « 



SECONDARY AFFECTIONS. 127 

ttfrise. But some have distinguished, under the name of measly 
eruption, one of the varieties of it, where the spots are clustered 
in groups, and distinctly somewhat elevated, so as to resemble 
closely the eruption of rubeola. This form appears to occur in 
the same circumstances with the diffuse pale petechia?, namely, 
in cases of typhoid fever and in the typhoid stage of synochus ; 
there seems no practical reason for viewing it as a distinct erup- 
tion ; and, indeed, the one form may be observed passing into 
the other, both in the same case, and in different cases of fever. 

Allied to petechia, in all probability, as to nature, are the 
vibices, which sometimes show themselves late in fevers of the 
typhoid type, and also, though more rarely, in the early period of 
those which commence with an inflammatory stage. These are 
large spots, varying in size from that of a pea to that of a half 
crown or upwards, of the colour of venous blood, diffusely cir- 
cumscribed, roundish or irregular, sometimes with, but more 
commonly without elevation of the skin, and bearing a consider- 
able resemblance to the marks of bruises. They are most gene- 
rally seen on the parts on which the body rests, the shoulders, back, 
nates, calves, heels, elbows, ears, occiput; but not unfrequently 
they are also seen on every other part of the body except the 
face. They are, in the majority of cases, connected with great 
depression of the pulse and exhaustion of the nervous system; yet 
sometimes, like the analogous eruption of hemorrhoza petechialis, 
they are rather associated with a state of reaction, and appear, 
therefore, early in the disease, and in those types which are 
inflammatory at the commencement. They occur only in the 
most severe cases ; and, in typhoid fever, they are for the most 
part of fatal import. If the patient escape the typhoid exhaustion 
which they accompany, they are apt to lead to gangrene in those 
parts which are subjected to pressure. 

[Dr. Christison has confounded the exanthematous eruption, 
or rash, by many regarded as characteristic of typhus, with the 
vascular extravasations known as petechias. As a diagnostic 
symptom of the disorder, it has only been carefully studied within 
a few years. It was noticed by Rogers, in the fever which pre- 
vailed in Ireland, during the year 1731; by Huxham in 1734-5; 
by Sir John Pringle in 1750; and by others. Hildenbrand 
described it, in 1806, more particularly than any other previous 
writer. There is no doubt but that continued fever of a low type 
occurs both without petechia or the exanthematous rash; and 
that both may occur successively, or together, or each may be 
present alone. Borsieri speaks of febins petechialis sine pete- 
chiis. And in the epidemic of Prague of 1740, it was remarked 
that whilst French soldiers were exempt from petechias, the 
inhabitants were covered with them. Dr. Watson observes, that 



128 CONTINUED FEVER. 

" it occurs in some epidemics more than in others. Fever is very 
rife in St. Giles, and in other crowded parts of this town just now 
(1838). Our wards at the Middlesex are full of it; and scarcely 
a case presents itself without these spots. We speak of it fami- 
liarly as the spotted fever ; or from the resemblance which the 
rash bears to that of measles, as the rubeoloid fever." He adds, 
" You cannot well confound this mottled rash with petechia, 
which are little specks, or dark circular spots, resulting from a 
minute extravasation of blood beneath the cuticle. The specific 
rash and these petechia? are, however, sometimes mingled to- 
gether." Dr. Copland holds this language : — " If I refer to my 
own observations in different parts of the continent, some time 
after the late war, and in various parts of this country, both 
before and subsequently, I shall find, 1st. That petechia; and 
vibices were either seldom or rarely seen for several years in some 
epidemics, excepting in the most severe or malignant cases, or 
when favoured by a too stimulant treatment and a too heating 
regimen during the early stages ; and that, at other times, they 
appeared more frequently in the advanced periods of the lowest 
forms of fever, and even, although much more rarely, towards 
the termination of synochoid fever, when antiphlogistic remedies 
had been neglected in the stage of excitement. 2d. That this 
change in some epidemics was a very common or even general 
symptom, occurring in mild as well as in severe cases, although 
presenting very different appearances in each ; and that they were 
sometimes observed early in the low states of fever, particularly 
when caused by unwholesome and deficient food, by a foul 
atmosphere, or by infectious miasms. 3d. That they were very 
frequently connected, especially in the plethoric, in the previously 
unhealthy, and in persons using much animal food, with evident 
change of the circulating fluids, with predominant disorder of the 
digestive organs, with a soft, broad, and open pulse, and with 
hemorrhages from the intestines, and a tendency to disorganization 
of the mucous surface of the bowels. 4th. That an exanthema- 
tons rash or eruption was observed in some epidemics, from the 
third to the eighth day of the fever, was quite distinct from pete- 
chia?, generally appeared earlier, and was, in some cases, either 
associated with, or succeeded by, petechia? or vibices, or even 
both. 5th. That this exanthema was of a reddish colour, varying 
in deepness, and rarely passing to a dark hue ; that it occurred in 
cases characterized by vascular reaction in the early stage, as 
well as in those of a very low grade ; in the mild, in the com- 
plicated, and in the severe ; that this eruption was most probably 
overlooked in many cases where it existed ; and that it was very 
generally confounded with petechia?, owing to its late appearance, 
or to its colour changing, in a somewhat similar manner to pete- 
chia?, with the states of vital power and of the circulating fluids. 



SECONDARY AFFECTIONS. 129 

6th. That, although the difference between these affections of the 
skin has been insisted on by Hildenbrand and Naumann, it has 
been too widely drawn by them, and without due reference to 
the occasional association of both affections." Hildenbrand says. 
that they do not always exist, and that frequently they are not 
remarked, if not looked for attentively. Dr. Stewart remarks, 
"that the eruption of typhus was unnoticed at Edinburgh, until 
the attention of physicians was called to it by Dr. Peebles in 
1832,"* and adds, " that it is also well known to many, that pre- 
vious to a visit which Dr. Peebles made to the Glasgow Fever 
Hospital, in the spring of 1835, the exanthema of typhus, then 
found to be of general occurrence, had neither been looked for, 
nor registered in that institution, and was received as a new dis- 
covery." 

The eruption was general and characteristic in the epidemic 
fever which prevailed in Ireland during the years 1817, '18 and 
'19. Dr. Bracken states, that of about 250 cases which fell under 
his care, the majority had eruptions of spots of various appearance 
as to size, shape and colour, Drs. Barker and Cheyne state, 
that eruptions of different kinds very generally accompanied it. 
Dr. M. Barry, of Cork, evidently implies from his remarks, that 
its occurrence was frequent. Dr. Fitzgerald, of Clonmeil, ob- 
serves, that it occurred in four cases out of five ; and Dr. O'Connel 
says, that at Listowel, he did not see five cases of the fever unat- 
tended with the eruption. In Connaught, the same authors 
affirm, that it was a general symptom of the disease. Dr. 
Roupell states, that in St. Bartholomew's Hospital, London, the 
eruption of typhus occurs in seventy out of every hundred cases. 
Dr. West's testimony is to the same effect, or even stronger; for 
he thinks it probable, that in the cases in which no rash was 
observed, it had disappeared before their admission. Dr. Cowan 
has investigated the frequency of the eruption in the Glasgow 
Fever Hospital, in upwards of two thousand cases, during the 
years 1S35-36; and his results are the following: — At the close 
of the year, in 76-16 per cent, of the males, and 71-77 of the 
females ; giving as an average of the whole cases 73-79 out of 
every hundred admitted. Dr. Henderson remarked the erup- 
tion in 108 out of 130 cases admitted in the Edinburgh Royal 
Infirmary. In the Glasgow Fever Hospital, from May 1st to 
November 1st, 1839, during which time the presence or absence 
of eruption was carefully noticed, the proportion was as follows : 

* [This is not altogether correct; for Dr. Alison, in 1827,a described it as a 
very frequent symptom of the epidemic which prevailed in Edinburgh about that 
period, occurring in a majority of the cases. 

e Ed. Med. & Surg. Journ., vol. xxviii.] 



130 CONTINUED FEVER. 





Males. 


Females. 


Total, 


Cases with eruption, 


224 


217 


441 


Cases without eruption, or doubtful, 


130 


120 


250 



691 

Dr. Peebles (1835) found the eruption as constant as any ex- 
anthema of other eruptive diseases. In the Philadelphia epide- 
mic of 1836, Dr. Gerhard says of the rash, that " it was present 
in thirty-two out of thirty-six whites. Of the four cases in which 
it was not visible, one died upon the seventh day of the disease, 
and the others presented slight symptoms of fever, which disap- 
peared in the course of four or five days. It was also visible, 
though less distinctly, in mulattoes ; and we may infer that colour 
of the skin alone prevented its development in the negroes." In 
the winter epidemic of this country in 1812-13, spots on the skin 
occurred in most of the cases at the commencement of the disease 
in 1S07 ; the next year they were less frequent ; and in subsequent 
years they were not met with at all before death. 

Another fact which strongly supports the opinion that typhus, 
in a great majority of cases, is attended with an eruption, is the 
fact mentioned by Dr. Davidson, ( Thackery Prize Essay, p. 22,) 
that " almost all the instances of fever which have occurred during 
the last six or seven years among the physicians, clerks, nurses, 
&c, of the Glasgow Fever Hospital, have been accompanied with 
this exanthema. We have made most careful inquiries respecting 
this point, and have only heard of one or two exceptions, amongst 
at least one hundred cases." 

According to Dr. Copland, the eruption usually appears from 
the third to the seventh day of the fever ; but may be delayed to 
the twelfth or fourteenth day. Dalmas (Diet, de Medecine, t. 
xxix., p. 859), says, that it is about the third or fourth day that 
the eruption manifests itself; but that it may be delayed much 
later. Borsieri mentions that in one of his patients it did not 
make its appearance until the fourteenth day. Hildenbrand 
fixes the fourth day for its manifestation. Dr. Stewart ascertained 
the exact time of the appearance of the eruption in fifty-two 
cases; this time varied from the second to the thirteenth day; but 
in twenty-nine cases, more than half of the entire number, it 
appeared on the fifth or sixth day ; and in three-fourths it appeared 
from the fourth to the seventh day. Dr. Henderson's observa- 
tions correspond with those of Dr. Stewart ; he noticed, that as 
a general rule, the progress and development of the eruption cor- 
responded with the increasing severity of the other symptoms of 
the disease. Dr. West states that in his cases it first showed 
itself from the sixth to the eighth day. In the Irish epidemic of 
1817, 'IS and '19, the rash appeared about the fourth or fifth day; 
rarely earlier. In Dr. Gerhard's cases the eruption appeared 



SECONDARY AFFECTIONS. 131 

from the sixth to the eighth day after the commencement of the 
disease. In forty-eight cases observed by Dr. Stewart, the erup- 
tion began to decline, at dffferent periods, from the eighth to the 
nineteenth day. It was still more irregular in the time of its dis- 
appearance, since this ranged from the thirteenth to the thirty- 
first day. The average duration of the eruption was eleven and 
a half days. Dr. Henderson found that the decline of the erup- 
tion was nearly simultaneous with the first signs of convalescence. 
In the Philadelphia epidemic it gradually faded away and disap- 
peared from the fourteenth to the twentieth. Dr. Watson says, 
that it sometimes disappears entirely after two or three days ; 
sometimes it lasts a fortnight or more. According to Copland, 
the duration is from three to five days. When the exanthema is 
slight, it disappears without leaving discernible marks; but when 
it is exuberant, stains are left in the situation of the papulae. 

Huxham describes the eruption as an efflorescence like the 
measles, but of a more dull and lurid hue, in which the skin, 
especially on the breast, appears, as it were, marbled, or varie- 
gated. Pringle's description corresponds; he says: — "There are 
certain spots, which are the frequent, but not inseparable, attend- 
ants of the fever in its worst state. They are of the petechial 
kind, of an obscure red colour, paler than the measles, not raised 
above the skin, of no regular shape, but confluent." Dr. Bracken 
describes them as of a diffused appearance, gradually shading off, 
and insensibly disappearing, and of the size of a grain of hemp- 
seed, though sometimes much larger, or smaller. Drs. Barker 
and Cheyne speak of it as a rash much resembling measles. Dr. 
Stewart, who studied the characters of the rash with great care, 
says that it is permanent ; " that is, that it does not consist of suc- 
cessive eruptions of spots ; that, in all cases, it presents the two 
periods, longer or shorter, of increase and decline ; and that, in the 
more severe cases, it may exhibit, during the period of increase, 
four different states, being florid, dark, livid and petechial. When 
the hue of the eruption is florid, it disappears readily under pres- 
sure ; when dark, it still disappears, but more slowly ; when livid, 
semi-petechial, or pseudo-petechial,as it has been called, it is only 
partially effaced; and when petechial, it is not in the least affected 
by pressure. In many cases it remains florid throughout ; in 
others it presents one or more, and in not a few all these altera- 
tions ; and after it has reached its height, the process is inverted, 
and it passes through the various phases of lividity, darkness, red- 
ness, and paleness, before its evanescence. Of one hundred and 
thirty-nine cases of typhus observed by Dr. Stewart, the eruption 
was pale in about one-fourth ; florid in between one-sixth and 
one-seventh ; darkish in between one-eighth and one-ninth ; livid 
in rather less than one-ninth ; and petechial in about one-eighth." 



132 CONTINUED FEVER. 

Dr. Copland says, that where petechia and the rash exist together, 
" they are quite distinct and different in their appearances ; for 
the latter is never so dark or livid as the former generally is, and 
the petechia? are not attended by the elevation of the cuticle and 
roughness characterizing the eruption. The stains left by an 
exuberant eruption generally become livid when petechia? are 
present ; but the eruption itself does not assume a dark tint as long 
as it retains its papular form. In the more malignant cases, and 
when petechia? appear early in the disease, the colour of the 
eruption may, however, become deeper, or may change with the 
alteration in the fluids and softer solids/' This eruption exists 
upon the breast, neck, shoulders, arms, back and thighs ; rarely 
on the face or hands. It has been seen upon the lips. Pringle 
mentions an instance where the only spot it appeared on was the 
arm immediately below a ligature applied in the operation of 
venesection. Borsieri avers that they are more frequent in those 
places where cups have been applied.] 

Gangrene and sloughing, however, are more commonly pre- 
ceded, not by vibices, but by erythema merely. An erythematic 
inflammation, affecting first the mere surface of the true skin, and 
gradually extending deeper, is a frequent occurrence in severe 
continued fevers, which present a marked typhoid character in 
the latter stage. It may occur wherever the body is subjected to 
pressure from its position; but is much more frequent on the 
nates, the lower end of the sacrum, and the back of the shoulders, 
than anywhere else. If not arrested by remedies, or by the early 
resolution of the fever, it is extremely apt to put on an ash-gray 
colour on the surface, which is an almost infallible mark of ap- 
proaching gangrene of the part. Sloughing, of course, ensues ; 
and the patient may die exhausted of this disorder after he has 
recovered from the proper symptoms of fever. A fatal event, 
however, is by no means so frequent in these circumstances as 
might be looked for. If the nervous system rallies from the state 
of typhoid depression, the sloughs for the most part separate, the 
cavities heal up by healthy granulation, and complete recovery 
takes place. In some epidemics vibices and erythema with con- 
sequent sloughing, are unusually prevalent, and then occasion 
many deaths, especially in persons beyond the middle term of 
life. 

[Gangrenous sloughs and ulcerations seem to be common in 
some epidemics of typhus fever and rare in others. At Philadel- 
phia, in 1836, they were present in only three or four cases in a 
hundred. Dr. Pickels says, that gangrene of the hips, nates, and 
shoulders was frequent during the epidemic at Cork, in 1817, 
1818 and 1819. Dr. O'Brien, in his Cork Street Hospital Report 
for 1820, informs us, that ulcerations and gangrene of the hips, 



SEQUELS. 133 

nates, and sacrum were of very common occurrence ; few of the 
malignant and protracted types of fever being exempt from them. 
Dr. Percival of Dublin says, "gangrenous extremities were ex- 
tremely rare amongst my patients."] 

Erysipelas is at times a rather common, and always a very 
troublesome, secondary disorder. It occurs chiefly when idio- 
pathic erysipelas prevails, and, above all, when it is epidemic in 
hospitals, as secondary to wounds and operations. In fever the 
usual period for erysipelas manifesting itself is rather after the 
crisis has begun to form, than during the full height of the fever. 
It appears, like idiopathic erysipelas, most commonly on the face 
and head; and it runs precisely the same course, sometimes ter- 
minating early in symptoms resembling meningitis, sometimes 
leading to spreading inflammation of the cellular tissue underneath 
the skin, and serous effusion or sloughing; sometimes resolving 
itself simply, or by vesication. It is always an unfavourable oc- 
currence; and a large proportion of cases, where it is unequivocally 
formed, prove fatal. 

The only other eruption of the skin which requires notice is 
Miliaria. Frequently in the inflammatory type of continued 
fever, and much more rarely in its typhoid forms, an eruption 
appears over the body generally, but in particular over the breast, 
shoulders, neck, and abdomen, consisting of small white, rarely 
reddish spots, of the size of a pin's head, distinctly elevated, and 
filled with a clear fluid. They appear, for the most part, rather 
early in the disease. Sometimes they seem connected with sweat- 
ing, break out immediately after a diaphoretic crisis, and then 
constitute what authors term sudamina. Frequently, however, 
they show themselves during the height of high inflammatory 
fever, and before the appearance of sweating. They are a 
favourable sign rather than the reverse; at least they occur most 
frequently in those forms of fever whose average mortality is the 
lowest — namely, where reaction is the predominating character. 



III. SEQUELiE. 

-To the foregoing observations on the secondary disorders which 
accompany continued fever, may be appropriately annexed a 
sketch of its sequelae. 

Here, in the first instance, it may be observed that serious se- 
quelae are, on the whole, rare; that the body generally rallies 
promptly and steadily from an attack of ordinary fever, when 
convalescence is fairly established ; and that the restoration to 
health is seldom interrupted by incidental diseases. Such is found 
to be remarkably the case with young persons between puberty 



134 CONTINUED FEVER. 

and early manhood. In them it is very commonly observed, 
where no infirmity of constitution preceded the fever, that the 
body becomes even more robust than before ; some infirmities of 
constitution, such as dyspepsia or derangements of the bowels, 
seem to be carried oft'; and not unfrequently young adults, who 
have ceased, or nearly ceased, to grow, gain a considerable acces- 
sion of stature during the short period of their illness. Serious 
sequelae present themselves chiefly in the following circumstances: 
— where marked infirmity of constitution preceded the attack of 
fever; where the patient has been imprudently subjected to some 
rash exposure during early convalescence, or commits some other 
important error in regimen ; and, finally, where the individual is 
considerably past the middle term of life. Even under these co- 
operating circumstances sequelae are rare ; and fever really seems 
to deserve the reputation it has long enjoyed, of having a tend- 
ency to carry off the seeds of lurking diseases. Many instances 
of apparent sequelae are nothing else than the full development of 
inveterate maladies, formed before, and merely latent. 

Among the sequelae may first be mentioned Relapse. The 
other consequences which have been witnessed, or alleged to 
occur, are principally rheumatism and neuralgia — partial palsy — 
oedema and phlegmasia dolens — various febrile inflammations, 
especially peritonitis and pleurisy — phthisis pulmonalis and 
mania. 

Relapses are apt to occur more or less after all continued fevers; 
but they are rare in those of the typhoid type : they are more fre- 
quent in synochus; and most frequent in mere inflammatory 
fever. In the inflammatory epidemic of 1817-20 in Edinburgh, 
they occurred, according to Dr. Welsh, in no less than almost a 
fifth part of the cases. When they occur in typhus, and even in 
synochus, they may commonly be traced to some error in diet or 
regimen, most generally to the former. It is well known that, 
even in health, the digestion of a meal is followed by a certain 
degree of exaltation of the pulse and animal temperature, con- 
stituting a kind of febricula. During convalescence from con- 
tinued fever, especially in the young, this excitement is often very 
considerable, the pulse rising from 60 or 70 to 90, the heat of the 
skin also increasing, the pulse at the temples throbbing somewhat, 
and the general disturbance coming to a close in two hours or 
more by the supervention of diaphoresis. Where the patient vio- 
lates the rules of correct regimen by imprudent excesses in eat- 
ing during early convalescence, this febricula is apt to pass into 
confirmed pyrexia, and his fever is renewed. Relapses, from 
whatever cause they spring, are commonly ushered in with an 
attack of rigor or great chilliness: and vomiting is not unfrequent 
also. The symptoms may afterwards present all the severity of 



SEQUELS. 135 

the original attack, or even more ; and occasionally they prove 
fatal. But, for the most part, they are slighter ; and their ave- 
rage mortality is unquestionably much less. A remarkable fact, 
formerly quoted in support of the doctrine of the essential cha- 
racter of continued fever, is, that in relapse secondary affections 
are decidedly more uncommon than in the primary attack. 

[True relapses rarely occur in typhus. Any difference of opin- 
ion on this subject among authors, would seem to arise from dif- 
ferent meanings being attached to the term. Relapses, according 
to many writers, do not mean a return of fever after complete 
convalescence, but a return of the symptoms with their former 
intensity, after a partial recovery, or, more properly speaking, a 
remission. When relapses take place, there is generally local or- 
ganic disease. In all the cases of typhus admitted into the Glas- 
gow Fever Hospital, from May 1st to Nov. 1st, 1839, there was 
not a single relapse into the same febrile state, characterized by a 
new eruption, and the other distinctive marks of the disease. 
(Davidson.) In the Irish epidemic of 1817, relapses were very 
rare. Dr. Veitch, Physician to the County Infirmary, Galway, 
says that he did not observe one case of relapse out of several 
hundred cases of fever. Dr. Henderson affirms that typhus never 
relapses. Out of 1600 or 2000 cases, he himself never met with 
one instance of relapse ; the only affections which might have 
been termed relapses, being febrile attacks dependent upon the 
existence of some local inflammation occurring during conva- 
lescence. Speaking of the celebrated epidemic of typhus, which 
occurred in Glasgow, Dr. A. P. Stewart observes, that he has 
never, among thousands of cases, seen a single case of relapse, 
in the proper sense of the term, after the symptoms had begun to 
decline. Dr. Perry's testimony is to the same effect. He states 
of 1145 cases of typhus treated by him in the Glasgow Hospitals, 
in 1831, nineteen of the so-called relapses occurred ; but all these 
were either cases of fever supervening upon some local inflam- 
matory affection, and caught in the hospital, or local affections 
occurring during convalescence from the fever. He adds, " that 
it is as absurd to talk of a relapse of typhus, as to talk of a relapse 
of small-pox or measles." Dr. Edward Percival states, that 
relapses were extremely rare at the Hardwicke Fever Hospital ; 
and Dr. Alfred Hudson says, that of five hundred cases of fever 
admitted into the Navarre Hospital in 1840, only two instances 
of true relapse occurred.] 

In one form of fever, namely Synocha, the circumstances of 
relapse are sometimes exceedingly singular and interesting. In 
the synocha, formerly described as having been common in Bri- 
tain during the earlier part of the last twenty-five years, and 
where the fever in a considerable proportion of cases was ab- 
ruptly resolved by a fit of copious sweating, relapses were so ex- 



136 CONTINUED FEVER. 

ceedingly frequent, as to have been thought by some, not without 
an appearance of reason, to constitute a part of the primary 
attack, rather than to merit the name of relapse in the strict mean- 
ing of the term. In the cases alluded to, the patient's conva- 
lescence went on steadily and swiftly for a few days, till at length 
the pulse became perfectly natural, the tongue clean and moist, 
the appetite good, the digestion natural, the strength much im- 
proved — in short, complete health seemed on the point of being 
restored ; when, at last, very regularly about the close of the thir- 
teenth or during the fourteenth day from the commencement of 
the primary attack, violent rigors set in, commonly accompanied 
with vomiting ; and, in an hour or two, the whole symptoms of 
synocha, as described above, succeeded in regular order and in 
great force. This state lasted for three days, when the fever again 
ceased abruptly with profuse perspiration ; and afterwards conva- 
lescence went on steadily, and without farther interruption.. It 
seemed that no precautions as to diet and regimen were of any 
service in averting this relapse ; it was as frequent among those 
who were confined to bed and kept on low diet, as where con- 
siderable latitude was allowed upon an opposite system ; and the 
latter cases generally had rather a milder attack. Relapse was 
far more rarely attended with local inflammation than the pri- 
mary attack. It was very seldom fatal. In one or two instances 
only it was protracted into a synochus, and proved fatal in this 
shape. 

[This is another point of the resemblance between this epide- 
mic and that in Scotland in 1843, already pointed out. (p. 86.) In 
the five-day form, which occurred with the typhus in Ireland in 
1817, Drs. Barker and Cheyne speak of the tendency to relapse.] 

Partial Rheumatism and Neuralgia are common sequelas of 
continued fevers of all kinds. They usually show themselves 
during convalescence in its early stage, and most frequently after 
fevers tending more or less to the inflammatory type ; but, abor e 
all, subsequently to synocha, where it terminates by diaphoretic 
crisis. The parts most commonly affected are the shoulders. It 
is an affection which may be the source of much suffering for the 
time ; but it seldom lasts out one week, always disappearing with 
the return of strength. Acute rheumatism is rare, and arises, like 
its attacks in ordinary circumstances, under some decided expo- 
sure, and probably in the predisposed alone. Persons conva- 
lescing from fever generally retain for some time a power of 
resisting exposures without injury, to a degree which would not 
be anticipated. There are exceptions ; yet, certainly, the gene- 
ral rule is, that, after attacks of fever of moderate duration, the 
body, however much reduced, withstands cold with unusual 
facility. 



SEQUELS. 137 

A remarkable sequela, not frequent, yet sufficiently so to have 
attracted the attention of those conversant with fever in the epi- 
demic form, is Partial Palsy. The parts most generally observed 
to be affected are the deltoid muscles, and the joints of the knees 
and ankles ; but the muscles of the face, at times, also suffer. The 
paralysis of the particular muscle, or of the particular movements 
of a joint, is sometimes complete, more frequently incomplete, 
seldom attended with any diminution of sensation, occasionally 
accompanied by pain, more generally not, and altogether inde- 
pendent, either of signs of an affection of the head, or of any 
appreciable disturbance of the circulation or digestion. When it 
affects the limbs, it has been mistaken by the inexperienced for 
an affection of the spine, and treated accordingly by persons who 
find in that organ a cause for every disorder which is to them 
otherwise unintelligible. But, for the most part, it ceases gradu- 
ally after convalescence is firmly restored, and it is best managed 
by invigorating treatment and regulated exercise. Sometimes, 
however, it is very inveterate. 

CEdema has been mentioned by most writers on continued 
fever as a frequent sequela in severe cases. As confined to the 
ankles only it is not altogether uncommon in early convalescence, 
when the patient first takes walking exercise ; but it is then a tri- 
vial complaint, dependent on mere debility, which never becomes 
considerable, and disappears as the strength returns. Anasarca 
of more considerable extent is, on the contrary, rare ; and though 
usually ascribed, in common with its slighter form, to debility, 
may be justly suspected to occur in connection with some old 
organic disease, and more especially with granular degeneration 
of the kidneys, or with diseased heart. 

During the early stage of convalescence, an affection occasion- 
ally presents itself, which resembles the Phlegmasia dolens of 
puerperal women, and is sometimes apt to be mistaken for oede- 
ma. It is generally preceded by some general fever. Its symp- 
toms are pain, swelling, tension, heat, and glistening whiteness of 
one limb, extending from the groin downwards, with inability to 
move the limb. It generally ends in resolution and recovery; but 
amendment takes place slowly, and sometimes it terminates in 
serous effusion and diffuse suppuration of the intermuscular cellu- 
lar tissue. It is in all probability a variety of subcutaneous cellu- 
lar inflammation. Of this affection, which was first described by 
Dr. Tweedie in 1828 as an occasional sequela of fever in the Lon- 
don Fever Hospital, several characteristic examples occurred in 
the epidemic of Edinburgh in 1817-20. 

Acute febrile inflammations are apt to occur during convales- 
cence from rash exposures; but they are not so common as might 
be expected. They are most frequently observed in the wards 



138 



CONTINUED FEVER. 



of hospitals, where all patients are often alike exposed to cool or 
cold air, whatsoever the stage of their fever, and, in particular, 
are at times subjected to local draughts of cold air from open 
windows. In cold weather an attack of coryza, with or without 
symptomatic fever, is frequent among those who go out of doors 
prematurely. The species of local inflammation which are most 
common, are pleurisy and peritonitis ; pneumonia and cynanche 
laryngea are less frequent. Peritonitis is the most common of 
them. These disorders generally put on a very acute character, 
commencing abruptly, and quickly running a fatal course, if not 
energetically treated. They seem to be more common after in- 
flammatory fevers, and after synochus with a well-marked inflam- 
matory stage, than after typhus. 

A good deal has been said of the tendency of continued fever 
to bring on phthisis palmona lis in the predisposed. The super- 
vention of phthisis is held by some to be in the ordinary course 
of events. But if long and intimate observation of the progress 
of several extensive epidemics in Edinburgh may be adequate to 
decide the point, then it seems clear that consumption is a very 
rare result, and its origin in fever as a predisposing cause, very 
problematical in any instance. Consumption is most frequent at 
the very ages when fever is most frequent. If one disease then 
led to the other, the concatenation ought to be witnessed so 
frequently as to be placed beyond all possible doubt as a fact. 
Nevertheless, it seldom happens that a fever patient exhibits 
symptoms of incipient phthisis on throwing off the febrile state ; 
and hence, where such an incident is observed, the presumption 
must be, that the seeds of the apparently supervening disease 
were sown before the attack of fever commenced. In most in- 
stances, indeed, this may be positively ascertained to be the case, 
on carefully inquiring into the history. Continued fever has 
clearly no particular tendency to lead to the formation of chronic 
organic diseases. On the contrary, as it has a marked tendency 
to remove functional disorders of the viscera — which, as already 
remarked, often disappear after an attack of fever — we may 
rather presume that organic diseases which originate in functional 
disturbances, must in that way be sometimes averted. 

Mania has been mentioned by some as an occasional sequela ; 
but in common with other affections of the brain, whether acute 
or chronic, functional or organic, it is of extremely rare occurrence. 
No better proof than this perhaps can be given, of the little con- 
nection subsisting between continued fever and inflammation of 
the brain, or any other organic disease there. In the fevers of Bri- 
tain no other organ is so frequently and so far disturbed in its func- 
tion while the disease lasts ; yet scarcely any other shows so little 
tendency to retain the traces of disease after the fever has thoroughly 



PREVALENCE, DURATION, AND MORTALITY. 



139 



subsided. In some instances a certain feebleness of intellect re- 
mains for a few weeks, as shown by listlessness of the faculties, 
indisposition to mental exertion, sluggishness in conversation, and 
defective memory. But this state very seldom outlasts the restora- 
tion of the muscular strength. More generally the mind is, from 
the commencement of convalescence, in a state of integrity, and 
eventually is found to become more acute. Sometimes, too, there 
is from an early period of convalescence an extraordinary activity 
of the mind, clearness of thought, facility of expression, and bright- 
ness of memory, which even recalls incidents long forgotten. 



IV. PREVALENCE, DURATION AND MORTALITY. 

It may not be out of place to wind up the preceding account 
of the symptoms of continued fever, essential as well as secondary, 
by some notice of its prevalence, duration, and mortality, 

1. Prevalence. — It is not easy to obtain a distinct conception of 
the prevalence of fever, in consequence of the want of sufficiently 
extensive and accurate statistical tables, showing the amount of 
cases relatively to other diseases, and to the general population, for 
a moderate term of years. There is no question, however, that if 
the average of a number of years be taken, and the general popu- 
lation of towns as well as of the country be included, fever will 
be found to constitute the most frequent of all diseases, and to 
occasion a larger proportion than any other of the general mor- 
tality. 

The extent to which continued fever prevailsj both absolutely, 
and relatively to other diseases, varies greatly in different years 
in the same place ; it likewise varies much at the same time in 
places situated alike in most respects; and farther, places circum- 
stanced to all appearance very much in the same manner, present 
marked differences in their liability to the disease at all times. 

The progress of epidemic fever through a series of years is very 
well shown by the following table of its history in Edinburgh 
since 1817, founded on the documents in possession of the Fever 
Board. The numbers show only those cases which were sent into 
hospitals : 





Years. 


Cases. 




YeaTS. 


Cases. 




Years. 


Cases. 


Nov. 


1817 






1826 ■ 


. 697 




1833 


- 878 


to Nov. 


1819 ■ 


• 2470 




1827 - 


1837 




1834 - 


- 690 




1820 • 


• 620 




1828 ■ 


1862 




1835 , 


- 826 




1821 ■ 


413 


Nov. 


1829 • 


■ 619 




1836 


- 841 




1822 - 


• 356 


to Mar. 


1830 - 


163 




1837 


- 972 




1823 - 248 




1831 ■ 


■ 191 




1838 ■ 


• 1994 




1824 - 


. 218 




1832 ■ 


• 1225 


to Mar. 


1839 - 


1981 




1825 • 


■ 328 








to Oct. 


1839 - 


338 



140 



CONTINUED FEVER. 



The best view yet given of the prevalence of fever in a great 
town is to be found in the excellent statistical account of fever 
recently published by Dr. Cowan of Glasgow. By uniting two 
of his tables, the following valuable facts are obtained for a period 
of forty-three years prior to 1838, showing the prevalence of fever 
in that class of the population which resorts to hospitals, so far as 
may be deduced from hospital admissions merely: 



Year. 


Population. 


Admissions. 


Year 


Population. 


Admissions. 




General. 


Fever. 




General. 


Fever. 


1795 . 


66 ; 578 


226 


18 


1817 


_ 


1886 


714 


1796 


- 


338 


43 


1818 


- 


3254 


2336 


1797 


- 


545 


83 


1819 


147,197 


2825 


1594 


1798 


. 


569 


45 


1820 


_ 


1570 


289 


1799 


- 


631 


128 


1821 


147,043 


1454 


234 


1800 


- 


733 


104 


1822 


- 


1596 


229 


1801 


83,769 


702 


63 


1823 


. 


1759 


269 


1802 


- 


729 


104 


1824 


. 


2091 


523 


1803 


- 


806 


85 


1825 


. 


2438 


897 


1804 


. 


678 


97 


1826 


. 


2317 


926 


1805 


- 


719 


99 


1827 


. 


2725 


1084 


1806 


- 


700 


75 


1828 


- 


3133 


1511 


1807 


- 


726 


25 


1829 


- 


2321 


865 


1808 


- 


840 


27 


1830 


\ - 


2010 


729 


1809 


- 


886 


76 


1831 


202,426 


3183 


1657 


1810 


- 


935 


82 


1832 


. 


4119 


2733 


1811 


110,460 


826 


45 


1833 


- 


3082 


1288 


1812 


- 


877 


16 


1834 


- 


3879 


2003 


1813 


- 


1022 


35 


1835 


- 


3260 


1359 


1814 


- 


1135 


90 


1836 


. 


5130 


3125 


1815 


- 


1340 


230 


1837 


. 


7200 


5387 


1816 


- 


1511 


399 











For nine years of this period, prior to 1837, the same author 
has supplied the number of fevers treated at home by district 
medical officers paid for the purpose; and when the above num- 
bers are corrected by the data thus furnished, the prevalence of 
fever will be found to stand as follows, for a population of about 
200,000 inhabitants : — 



Years. 


Cases. 


Years. 


Cases. 


Years. 


Cases. 


1828 


. 2511 


1832 


■ 3825 


1835 ■ 


. 1686 


1829 ■ 


• 2205 


1833 


- 1675 


1836 • 


3841 


1830 


. 1089 


1834 


• 2402 


1837 


- 7707 


1831 


• 1249 











It is probable that of all the great towns in Britain, Glasgow 
has been for some time the most unfavourably situated as regards 
fever; and the statements of Dr. Cowan undoubtedly show a 
fearful increase in the extent of its devastations. But other great 
cities are not much behind it in this respect. In Edinburgh, for 
example, during four severe epidemic visitations since 1816, each 
lasting between three and four years, the number of beds constantly 



PREVALENCE, DURATION, AND MORTALITY. 141 

occupied in -the hospitals has varied from 120 to 150 ; and for some 
time past (Jan. 1339), the latter number has been often insufficient 
to meet the demands for admission. A very remarkable fact is, 
the slight extent to which fever prevails in some of the large towns 
in England, and the improvement which has gradually been at- 
tained in that respect with them, while in Glasgow and Edinburgh 
the case stands directly the reverse. Dr. Cowan shows that, while 
in Glasgow, with a population of 200,000, the annual average of 
fever, deduced from seven years ending with 1S36, has been 1842 
cases, in Manchester, with a population of 228,000, it has been 
for the same period only 497 ; in Leeds, with a population of 
123,400,only 274; and in Newcastle, with a population of 58,000, 
so little as 39. And he likewise states, that while in Glasgow the 
average fevers treated annually in hospitals, between 1797 and 
1806, was 88, and has latterly increased to 1842; in Manchester 
the average has stood nearly the same, notwithstanding the great 
increase in its population, having been 462 in the early period, 
and 497 recently. 

The statistical results of hospital experience, even when cor- 
rected by that of institutions for visiting the poor at their own 
houses, give probably a very imperfect idea of the real preva- 
lence of fever in a community. In periods where there is no 
epidemic alarm, it seems likely that but a small proportion of the 
cases come under the notice of the statistical inquirer. And even 
in seasons of epidemic virulence, when the poor more readily 
seek assistance from public institutions, it would appear from the 
researches of Dr. Cowan, that little more than one-third of the 
fevers in a great city are accounted for in this way. In 1835-7 
the cases of fever treated in hospitals, or by district medical 
officers, in Glasgow, were 1686, 3841, and 1707 — in all 13,234 in 
three years : but reckoning from the annual bills of mortality, in 
which the deaths from fever are specified, and from the average 
mortality of fever in hospitals during these three years, there 
must have been altogether in that city 6180, 10,092, and 21,800 
cases — or, in all, 3S,074 — very nearly three times the number 
accounted for. 

[Dr. Alison says, « For many years past contagious fever has 
never been absent from Edinburgh, and there have been three 
great epidemics of that disease in the last twenty-two years, 
beginning in 1817, 1826, and 1836, each lasting nearly three 
years, and each of the last two affecting, I believe, nearly ten 
thousand persons. The number of fever patients admitted into 
the Infirmary and Auxiliary Fever Hospitals from November, 
1817, to November, 1820, was 3090; from November, 1826, to 
November, 1829, it was 4318; and from October, 1S36, to Oc- 
tober, 1839, it was 4850." {Management of the Poor in Scot- 
landy 2d ed., p. 8 : Ed., 1840.) Probably not more than half the 



142 



CONTINUED FEVER. 



cases which occurred during these epidemics were removed to 
the hospitals. Therefore the whole number of persons affected 
between 1836 and the close of 1839, must have been at least 
10,000, a calculation most likely below the actual number. From 
the Statistics on Fever published by Dr. A. S. Thompson, it ap- 
pears that fever is most prevalent from July to December. 

The following table this author has compiled from materials 
selected indiscriminately from all the reports which he could 
obtain, showing the number of fever cases admitted into the 
various hospitals in Great Britain and Ireland ; but he is chiefly 
indebted to Drs. Barker and Cheyne's account of the epidemic 
fever which prevailed in Ireland in 1817-18-19. 

Table showing that of 51,944 cases of fever admitted into different hospitals in 
Great Britain and Ireland, the number and relative ratio of admissions in each 
month were as follows: 



Months. 


Number of Cases 


Relative ratio of admis- 




admitted. 


sions per cent. 


January 


2895 


5-6 


February 


2825 


5-4 


March 


3152 


61 


April 


3374 


6-5 


May 


3990 


7-6 


June 


4365 


8-3 


July 


4999 


9-6 


August 


5261 


10-1 


September 


5046 


9-7 


October 


5624 


10-8 


November 


5054 


9-7 


December 


5359 


10-6 

100-0 


Total 51,944 



It appears from this table that the greatest number of fever 
cases were admitted into the different hospitals during the last 
six months of the year, or from July to December. And the 
number of cases admitted from January to June are few, com- 
pared with the admissions from July to December.* 

Dr. Duncan remarks, (First Report of Commissioners for 
Inquiring into the State of Large Towns, fyc., London, 1845, 
•Appendix,) that previously to the publication of the Reports of 
the Registrar-General, he stated his belief, founded chiefly on the 
records of dispensary practice, that 1 in 25 of the working popu- 
lation of Liverpool was annually affected with fever, and that 
this probably afforded a higher ratio than any other town in 
England. The maculated, or spotted fever, the true Typhus Hi- 

* [Edinburgh Medical and Surgical Journal.— July, 183S, p. 100.] 



PREVALENCE, DURATION, AND MORTALITY. 143 

bernictts, has probably always been endemic in Ireland. Ac- 
cording to Mr. Wilde, that fever has raged nearly decennially 
in Ireland for the last 150 years. He says, as a general rule, it 
appears that fever there has become epidemic from the eighth to 
the twelfth year, with an interval of from six to eight years. And 
facts, during the eighteenth century, go to prove this assertion, 
with the exception of two lapsed periods. Thus, there was an 
epidemic in 1708, one in 171S-21, 1728-31, 1740-43, 1763-64, 
1771-73, and 1817-21. The lapsed periods — the first from 1743 
to 1763, the other, of thirty-four years, from 1773 to 1817 — he 
seems to think may arise from deficiency of records for the period. 
One of the most appalling epidemics that ever invaded Ireland 
took place in 1817-18-19. Drs. Barker and Cheyne, its his- 
torians, state in their report, that " assuming the population of 
Ireland to amount to six millions, it will be no exaggeration to 
state, that a million and a half of persons suffered from an attack 
in the time included, between the commencement of the years 
1818 and 1819. In the course of the two years commencing 
with September, 1817, more than 42,000 persons were admitted 
into the hospitals." During this epidemic the total number of 
persons admitted into the hospitals (both temporary and perma- 
nent) was 100,737. 

From 1812 to 1820 typhus fever prevailed to more or less 
extent throughout the Northern and Middle States of this coun- 
try. Since then partial epidemics have occurred from time to 
time. In Philadelphia, in 1836, an epidemic typhus appeared, 
but was confined chiefly to a portion of the town inhabited by 
the lowest and filthiest blacks. Sporadic cases have appeared 
since occasionally. The form of continued fever most common 
in this country — at least the northern and middle sections — is 
the Typhoid Fever, or Synochus, of Cullen.] 

2. Mortality. — The mortality of fever has been made the 
subject of frequent investigation in all parts of Britain, and many 
important numerical statements have been published, which con- 
tribute to give a precise view of the influence of this scourge 
on the lives of the community. 

An exceeding difference prevails in the relative mortality of 
fever, under a variety of essential or collateral circumstances. 
In the first place, it is plain that some types of continued fever 
are much more fatal than others. Synocha is very rarely fatal ; 
synochus much more frequently; typhus the most fatal of all. 
Hence some epidemics are much more deadly in the same place 
than others. There is also a great difference in the mortality, 
from the same kind of epidemic, in different places ; and such 
differences are often little susceptible of explanation. In epi- 
demics presenting the inflammatory character the mortality has 



144 CONTINUED FEVER. 

been observed, for a length of time, and upon a great scale, to be 
so low as one in 22, one in 25, or even one in 30. This was the 
fluctuation of the hospital mortality in Edinburgh, during the 
latter part of the epidemic of 1S17-20; and an equally low ave- 
rage was observed in several parts of Ireland about the same 
period. In the recent epidemics of Edinburgh, which have as- 
sumed much more the typhoid or adynamic character, the ave- 
rage has been greatly increased. In the year 1826-7, in a total 
number of 1570 hospital patients, the mortality was one in 10-33. 
In the epidemic which has raged for some years past, the deaths 
have been still more numerous, in correspondence with a more 
purely typhoid type. The number of patients treated in the 
Edinburgh Hospital in 1837 and 1838 has been 1994 and 2606 ; 
and the proportion of deaths one in ten during the former year, 
and one in 6-27 during the latter. According to Dr. Cowan the 
average mortality, deduced from the observation of an unusual 
number of cases, was, in 1835-7, one in 15, one in 12, and one 
in 10. These proportions are much exceeded in some of the 
great cities of England — a fact which seems the more remark- 
able, that fever is in them much less prevalent than in Glas- 
gow or Edinburgh. According to Dr. Bardsley of Manchester, 
the annual hospital average in that city has varied, between 1818 
and 1828 inclusive, from one in 111 to one in 6£; and the ave- 
rage of the mortalities for all these years is one in 8i. In the 
London Fever Hospital for the same period, the averages, ac- 
cording to Dr. Tweedie, have fluctuated between one in 10 and 
one in 5 ; and the average of the whole annual mortalities of the 
period was so high as one in 6§. Much more fearful mortalities, 
however, have been recorded than any yet mentioned. In Guy's 
Hospital in 1816, Dr. Marcet found the deaths to amount to one 
in 4; and, for a short period in 1799, Dr. Willan ascertained 
that among the patients treated at home in connection with a 
dispensary in London, the average deaths were actually one-half 
of the seizures. The mortality is seriously affected by liability 
to the entero-mesenteric affection, which has been described above 
as a frequent accompaniment of some epidemics. If M. Louis's 
experience be a fair representation of the general experience of 
French physicians in fever, the mortality occasioned by this bowel 
affection is fearful ; for he lost 46 out of 132 patients, or one in 2-9. 
[The rate of mortality in continued fever must necessarily 
vary with circumstances — with the form of the fever, with the 
character of the epidemic, with the season, &c. Hence the great 
differences in the mortality as observed and stated by writers at 
different periods. The mortality in some epidemics of camp 
typhus has been frightful. Out of 400 refractory conscripts sent 
to the prisons of Gaeta, Due astaing relates that 300, or two-thirds, 
perished. At Dantzic, according to Tort, typhus carried off two- 



PREVALENCE) DURATION, AND MORTALITY. 145 

thirds of the garrison and a quarter of the population. Des» 
genettes states (Diet, des Set. Med., t. xv. p. 457), that of 25,000 
soldiers who escaped to Torgau in the disastrous campaign of 
1813, 13,448 died of typhus in the space of four months, more than 
one-half of the whole garrison of the town. At Antwerp, in 1814, 
Flettry states that one-half of those attacked died. Fauverges 
informs us that of 60,000 troops at Mayence, more than 25,000 died 
of typhus. At the hospital of La Charit6, at Paris, in 1814, in the 
wards of Dr. Fouquier, the mortality was only one in 3. At the 
hospitals of Posen, in 1830, Dr. Hertzog lost only one-eighth of 
his cases; Landouzy, at Rheims, in 1839, the same proportion; 
at the epidemic of Bourges, which had Dr. Boin for historian, the 
deaths were one in 9. In 1814, at La Salpetriere, Pinel tells us 
he lost but twelve persons out of 120 who were attacked, or one 
in 10. Delboog relates, that amongst the Spanish prisoners, 
placed under highly favourable hygienic conditions, the deaths 
were only one in 18§.* Dr. Alison found the mortality at all ages, 
as one in 9i. Hildenbrand estimated the deaths in exanthematic 
typhus at one in 10. From the Fifth Annual Report of the 
Registrar-General of England (1843), it appears that out of 
100,000 males dying under 5 years, 61 die of ague (intermittent 
fever), 61 of remittent fever, and 1086 of typhus. Out of 100,000 
dying at 5 and under 10, 107 die of remittent, and 7166 of typhus; 
at 10 and under 15, 10,405 die of typhus; at 15 and under 20 (of 
males), 216 die of ague, and 10,173 of typhus ; at 20 and under 
25, 6568 die of typhus ; at 30 and under 40, 3853 die of typhus; 
at 40, and under 50, 3591 die of typhus; at 50 and under 60, 56 
of ague ; 56 of remittent, and 2083 of typhus ; at 60 and under 
70, 1722 die of typhus; at 70 and under 80, 1440 die of typhus; 
at 80 and under 90, 186 die of remittent, and 186 of typhus. Out 
of 100,000 females under 5, 34 die of ague, 45 die of remittent 
fever, and 1144 of typhus; at 5 and under 10, 218 die of ague, 
327 of remittent fever, and 8052 of typhus ; at 10 and under 15, 
274 die of ague, 274 of remittent fever, and 8493 of typhus ; at 
J 5 and under 20, 9534 die of typhus ; at 20 and under 25, 5006 
die of typhus; at 25 and under 30,4333 die of typhus; at 30 and 
under 35, 60 die of ague, and 2776 of typhus ; at 35 and under 
40, 2615 die of typhus ; at 40 and under 45, 2376 die of typhus ; 
at 45 and under 50, 1544 die of typhus; at 50 and 55, 214 of 
typhus. The whole number of patients received into the seve- 
ral fever hospitals of Dublin, from August 31, 1817, to October 1, 
1819, was 41,775; and the deaths during this period were 1972, 
being about one in 22. The highest rate, for any single quarter, 
was one in 15; the lowest, one in 32. The average mortality, 
during the same epidemic, in the South Fever Asylum at Cork, 

* [Gaulthier de Claubry de l'Indentite, &c, p. 311.] 
10 



146 



CONTUSED FEVER. 



was one in 25.* The number of patients received into the Cork 
street Fever Hospital, of Dublin, between May 14, 1804, and 
January 5, 1806, was 20,278. In the year 1805, the highest 
mortality was one in 10; in 1815, the lowest, about one in 20 ; 
the average mortality for the entire period being one in 14.t 

During the great Irish epidemic of 1817-18-19, the total num- 
ber of persons admitted into the Irish hospitals was, as before 
stated, 100,737, of whom 4349 died. This is a small mortality 
relatively to the number attacked, being but one in 23. The 
mortality from fever in Ireland has been much exaggerated. In 
the most fearful epidemic of the last century, that of 1740-41, 
Dr. O'Connel states that the number that perished was 80,000 ; 
whilst Kulty says that it was computed, though probably with 
exaggeration, that one-fifth of the inhabitants died. In 1830, it 
was asserted before a select committee of the House of Com- 
mons, that 65,000 died of fever in 1817. What reliance, asks 
Mr. Wilde,J can be placed on such guesses, when it is dis- 
covered by statistics derived from sources much more accurate 
than former days possessed, that the mortality from fever in Ire- 
land, in ten years, (from 1831 to 1841,) was a little more than 
112,000. 

According to Dr. Duncan, the mortality of fever in Liverpool 
is not more than one in 12 or 15. Dr. A. S. Thompson § estimates 
the average mortality in Great Britain as one in 15 persons at- 
tacked by fever. He affirms, moreover, that the annual ratio of 
deaths from fever in London has decreased since the commence- 
ment of the 18th century. 

The following table shows the number of deaths from fever in 
the five principal towns of England during the whole period (3§ 
years) comprised in the Registrar-General's published Reports. 





Deaths by 


Total 


Per eentage 


Proportion 




Continued 


deaths. 


proportion 


of fever 


Towns. 


Fever. 




of fever 

deaths to 

others. 


deaths to 
population 
annually. 


Birmingham 


502 


12.224 


4*10 


1 in 917 


Leeds (Parliamentary Borough) 


661 


14,747 


4-48 


1 in 849 


London 


9,150 


189,379 


4-83 


1 in 690 


Manchester (three years) 


1,121 


19,969 


5-61 


1 in 498 


Liverpool and West Darby 


2,060 


33,022 


6-23 


1 in 488 


Liverpool (Parish) 


• 1,795 


26,456 


6-78 


1 in 407 



* [Trans, of Physicians of Ireland, vol. iii.j 
■j- [Dr. O'Brien, Trans, of Physicians of Ireland, vol. i.] 
i [Wilde on Causes of Death in Ireland, &c, in Census Report for 1845, Dub- 
lin, 1843, p. xxiii.] 
§ [Ed. Med. & Surg. Journ., July, 1838.] 



PREVALENCE, DURATION, AND MORTALITY. 



147 



The decreased mortality in London from fever, for the last hun- 
dred years, as exhibited in the bills of mortality, is remarkable. 
In 1750 the deaths from fever, in London, were almost one-fifth 
of the whole mortality; whereas lately, and an epidemic period, 
too, they have not exceeded one-tenth. The total number of 
deaths from fever in 1838, as shown by the returns under the 
new registration act, was 4078, at which time the population 
may be reckoned at 1,888,800; the mortality from fever was 
consequently 2-32 in 1000. The mortality from fever has slowly 
declined since 1838. (Brit, and For. Med. Rev., Jan., 1841.) 

The following statement is from Mr. Farr's elaborate article 
on Vital Statistics, in Maculloch's work, vol. ii. p. 579,) and 
may be fully relied on from the well-known accuracy of that able 
statistician. 



Mortality in London.-— Deaths to 100,000 living. 



Fever 

Spotted Fever 
Plague 
Scarlatina 


1629-35 


1660-79 


1728-57 


1771-80 


1801-10 


1831-5 


636 

45 
125 


785 

90 

1225 


785 


621 


264 


111 
53 




806 


2000 


785 


621 


264 


164] 



To these facts may be appended a sketch of the influence of 
fever on the general mortality from diseases at large. On this 
important subject few precise facts have been made public, from 
which the average influence of fever may be determined for a 
series of years. But an extremely interesting view has been 
given by Dr. Cowan, of the relation of deaths in fever to the 
general mortality during the prevalence of the late virulent epi- 
demic in Glasgow. In 1835-7 the deaths from fever alone were, 
according to the bills of mortality, which have been taken for 
some years past with unrivaled care, 412, 841, and 2180; and 
they constitute, in relation to the mortality from all diseases, one 
in 15-6, 10 and 4*7, annually; or, in the population at large, one 
in 570, 290 and 116. It has been supposed by some that epi- 
demics of fever, although they may constitute a large proportion 
of the sickness of a place, and occasion a large proportion of the 
total deaths, nevertheless do not sensibly add to the mortality ; 
and this statement is grounded on the fact, which seems well 
ascertained, that epidemics of fever, by seizing upon the feebler 
constitutions, occasion a palpable diminution of other diseases. 
The reason, however, may be true, and yet the inference false ; 
because fever, especially in the typhoid form, is a more formi- 



148 CONTINUED EEVEfc. 

dable disease than the average of prevalent disorders : and that 
the inference is wholly false, appears abundantly from facts con- 
tained in the paper of Dr. Cowan. In 1824 the deaths were only 
one in 37 in the city of Glasgow, while during the late epidemic 
of 1835-7, they have increased to one in 32-6, 28-9, 24-6. In 
1835-7 the total deaths from all diseases were 7198, 8441, and 
10,270; and, on deducting from these numbers the whole deaths 
from fever, there remain for other diseases 6786, 7600, and 8090 ; 
so that, contrary to the common notion, the same causes which 
have increased so much the devastations from fever, have actually 
also increased the casualties from other diseases at large. 

Duration.— It was stated under a previous section, that the 
duration of fever varies exceedingly, from a few days to several 
weeks ; that inflammatory fever is often resolved abruptly be- 
tween the fourth and ninth days, leaving nothing to be recovered 
from except debility and emaciation ; and that typhus and syno- 
chus, on the contrary, commonly continue between eleven and 
one-and-twenty days without abatement, but sometimes for a 
much longer period, nay, even for twice the longest of these 
intervals. That interval too may be prolonged by local disorders 
supervening. In the mixed epidemic of 1817-20 it appears from 
the tables of Dr. Welsh, that the average duration of fever be- 
tween seizure and the establishment of convalescence was twelve 
and one-third days ; but in the late typhoid epidemic the time 
must be somewhat greater. 

Convalescence in general proceeds more slowly in fever than 
in other diseases requiring similar treatment — probably because 
fever, by virtue of its two essential constituents, reaction of the 
circulation and nervous exhaustion, leads to more general dis- 
turbance and more extensive derangement of most of the animal 
functions. According to Dr. Weslh, the average stay of fever 
patients in hospital in the inflammatory epidemic of 1817-20, was 
very nearly twenty days ; and the average duration of the dis- 
ease at entrance was seven days ; so that four weeks may be 
taken for the period when patients are able to take care of them- 
selves. According to Dr. Cowan, the average stay in hospital in 
the more typhoid epidemic of Glasgow in 1S36 was eighteen 
days. This will give nearly the same ultimate result with the 
calculations of Dr. Welsh ; because, in consequence of the more 
insidious mode in which synochus and typhus have commenced 
in late epidemics, patients do not generally arrive in hospitals so 
early in the disease. Four weeks, however, by no means consti- 
tute the full amount of the duration of sickness, as estimated by 
the time the patient is absent from his usual occupations. Dr. 
Cowan considers six weeks a low average for expressing this 
fact ; and, from observation in the instances of medical students, 



ANATOMICAL CHARACTERS. 149 

where the whole circumstances may be accurately ascertained, it 
is probable that the real average is not less than two months. 



V. ANATOMICAL CHARACTERS. 

The pathological anatomy of continued fever remained, till 
lately, in a very crude and unsatisfactory condition. But no 
other topic has attracted so much attention during the last five- 
and-twenty years, or has been investigated with more success, 
so far as the accumulation of facts goes. Whether the result 
has been hitherto beneficial in reference either to pathological 
doctrine or medical practice, is a question which admits of some 
doubt. A very great variety of morbid appearances have been 
indicated as occurring in fever. Of these many are plainly inci- 
dental, because they do not, by any means, present themselves 
regularly. Others, however, have been held to be invariable ; 
and consequently authors have sought for the nature and essence 
of fever in the local morbid action which gives rise to such ap- 
pearances. On taking into account the general result of the 
observations of all pathologists of credit, it seems impossible to 
avoid the conclusions, that no morbid appearance is invariable 
except congestion of internal organs; that every other patho- 
logical fact which has been observed is not constant, and is, 
therefore, the effect of a secondary disease ; and that, in all the 
observations hitherto made on the pathological anatomy of fever, 
we must be content with discovering its consequences, not its 
causes. The information which has been amassed is important 
in a practical point of view, as turning the attention of practi- 
tioners to the necessity of studying and treating those secondary 
affections which, in various circumstances, are the occasion of 
suffering, danger, or death. But it does not seem to throw much 
light on the real essence of fever ; and, by being rashly assumed 
to furnish that light, it has led to grave theoretical and practical 
errors. 

In the first place there can be no question that cases of death 
from true continued fever, of the typhoid or synochus type, occa- 
sionally present themselves where no morbid appearance what- 
ever is detected, except congestion of internal organs. In such 
cases it is usual to find the sinuses of the dura mater somewhat 
turgid with blood ; the blood-vessels of the membranes of the 
brain more or less gorged, sometimes considerably so, and the 
substance of the brain unusually checkered with bloody points 
when cut across ; the bronchial membrane of the lungs dark and 
vascular; the intestines also vascular, and the vessels well- 
marked in consequence of being distended with dark blood ; the 
gastro-intestinal mucous membrane spotted here and there with 



150 CONTINUED FEVER. 

small points of ecehymosis, and in the depending parts with 
large brownish-red plates of extravasation into its substance, or 
rather into the submucous cellular tissue ; the mucous membrane 
of the bladder similarly affected ; and generally, too, the external 
surface of the body unusually discoloured by lividity, especially 
in the depending parts. In addition to these indications of vas- 
cular congestion, there is very commonly found some effusion of 
serosity into the ventricles of the brain, and into the subarach- 
noid cellular tissue, as well as accumulation of serous fluid in 
the back part of the lungs, together with darkness and brittleness 
of the injected tissue. That some of these appearances exist 
during life seems highly probable. 'The occurrence of conges- 
tion of the cerebral membranes is rendered probable by the 
visibly congested condition of some external parts, such as the 
skin and conjunctivas; and condensation of the posterior region 
of the lungs is often discoverable before death by the stetho- 
scope. Nevertheless, it is material to remark, that all the pheno- 
mena now mentioned come also under the denomination of 
pseudo-morbid appearances, and may be occasioned merely by 
the particular manner of death, that is, slow failure of the respira- 
tion before arrestment of the circulation, or by organic processes 
carried on during the first few hours which succeed the extinction 
of animal life. Hence much of the vascular congestion and serous 
effusion seen after death from primary fever may be, and indeed 
almost certainly is, pseudo-morbid ; at all events, equal conges- 
tion and effusion are frequently remarked after death from other 
causes, where there was clearly no affection during life, either of 
the brains, the lungs, or the intestinal canal. The last remark 
applies particularly to the congestion of vessels and effusion of 
serosity commonly observed within the head — appearances 
which have been imagined by one sect of non-essentialists to 
bear out their doctrine, that fever consists radically of cerebral 
inflammation. It also applies with equal force to the vascularity 
and submucous extravasation observed often in the stomach and 
intestines — to which single appearance the Broussaists are not 
unfrequently reduced, for evidence of their imaginary gastro- 
enteritis. 

The morbid appearances which occur incidentally, or as 
secondary affections, during fever, are chiefly either the several 
effects of inflammation of the internal organs, or softening and 
friability of their texture from an unascertained cause. The 
frequency of secondary appearances must be stated very differ- 
ently, according as we admit dothinenteritis to be a mere variety 
of ordinary fever, with a secondary disorder of the intestinal 
canal, or maintain that it is a distinct disease. If that affection 
be excluded, the secondary appearances observed in the dead 



ANATOMICAL CHARACTERS. 151 

body are few and simple. In the fever of Edinburgh, for exam- 
ple, where inflammation and suppuration of the intestinal muci- 
parous glands are rare, other morbid appearances are also, on 
the whole, not frequent. If, however, the abdominal disorder in 
question be regarded, not as a distinct disease, but as incidental 
to typhus, the number of pathological appearances, which must 
be included under the class of secondary phenomena, becomes 
very great; because that particular disorder never makes its 
appearance without being attended by very many others, se- 
condary to itself, and involving important structural derange- 
ments. In treating of continued fever hitherto, dothinenteritis 
has been considered one of its secondary disorders. It will, 
therefore, be right to follow out the same doctrine in the present 
place, and to enumerate all the pathological appearances which 
have been indicated in fever, with this understanding of the 
meaning of the term. 

[Dr. Alison, after observing the occasional entire absence, after 
fatal fever, of any appearances strictly morbid — that when found 
they are often remarkably various, even in cases, the leading symp- 
toms of which are nearly the same — and that they are far from 
bearing any fixed proportion to the intensity of the symptoms 
of affection of the parts where they exist, says — " when found 
after fever they are almost uniformly indications of inflammation ; 
but this inflammation is distinguished by two peculiarities ; first, 
that it is seated very generally in certain textures only ; and, se- 
condly, that its effects are apparently more limited than in other 
cases, and in particular the effusions of coagulable lymph and of 
pus are often found to a very small extent, in comparison with 
what is seen in idiopathic inflammation of the same parts. In- 
deed there are so many fatal cases of fever, attended with evident 
local affections, and showing on dissection marks of local inflam- 
mation, in which no effusion of lymph or pus appears on dissec- 
tion, that it may be suspected in the comparatively few cases 
where considerable effusions of these kinds have been described, 
that they had resulted from simple inflammation immediately 
succeeding, (as often happens,) to the fever, rather than that they 
had taken place during the fever itsel£"] 

1. The brain and membranes seldom present any other devia- 
tions from the healthy condition than those already enumerated. 
Sometimes vascularity and effusion of serosity are attended with 
opacity of the arachnoid. This opacity is conceived by many to 
be a character of inflammation, but probably without sufficient 
reason. A more unequivocal character, but an extremely rare 
fact in the pathology of fever, is effusion of distinct lymph on the 
surface of the arachnoid. It is usual to find authors speaking in 
general terms of inflammation being seen in the cerebral mem- 



152 CONTINUED FEVER. 

branes. By inflammation, however, they generally understand 
vascularity and turgescence only. Now these appearances are 
altogether fallacious diagnostics of inflammation. Mere vascu- 
larity of the cerebral membranes can scarce be satisfactorily re- 
ferred to inflammation, unless there are an extreme abundance 
and minute network of visible vessels occupying the superior as 
well as inferior parts in point of position, attended with an uniform 
pale rose or flesh-coloured blush, and by no means necessarily 
accompanied, indeed rather without, turgescence of the larger 
blood-vessels. These are the anatomical characters of cases of 
idiopathic meningitis fatal in its early stage ; but such characters 
are very rarely presented by the congestive vascularity often ob- 
served as the only unnatural condition of the membranes of the 
brain after fever. 

[Unusual engorgement of the sinuses and the larger vessels of 
the brain has been observed by most writers. Gerhard says 
these were filled, in his cases, with dark-coloured fluid blood, in 
some instances, in the large sinuses, surrounding a soft greenish 
coagulum. Injection of the pia mater is not uncommon ; and the 
arachnoid, according to Larrey, is sometimes opaque, and covered 
with a false membrane. Serum is found beneath the arachnoid, 
and in the ventricles ; of forty-three cases in which the brain was 
examined by Dr. Reid,* there was increased effusion of serum in 
twenty. This effusion in most cases, was situated between the 
arachnoid and the pia mater, and was commonly moderate in 
quantity, in many cases elevating the arachnoid above the surface 
of the convolutions only at the depending portions of the brain. 
Gerhard states, that in his dissections the medullary portion 
of the brain was frequently of a violet tinge; otherwise the 
substance of the organ was unaltered. In the spinal cord, similar 
appearances to those described in brain, have been observed. 
Gompte has found not only the spinal meninges affected, but 
the cord itself injected and even softened. Though effusion be- 
neath the arachnoid and in the ventricles is a frequent morbid 
appearance after continued fever, it is still to be found after death 
in cases where abundant cause of death existed elsewhere ; it is 
very generally much less than in fatal cases of idiopathic inflamma- 
tion within the cranium ; and it is more frequent in old than young 
persons. All this makes it difficult to determine how far it is an 
effect of fever. Dr. Reid says, that the cerebral symptoms — deli- 
rium, coma, subsultus — were as frequently present, and as strongly 
marked in the cases where there was no increased effusion, as 
where there was.] 

2. The part in which morbid appearances are most frequently 
found is the mucous membrane of the alimentary canal. The 

* [Ed. Med. & Surg. Journ.,Oct., 1839.] 



ANATOMICAL CHARACTERS. 153 

pharynx exhibits sometimes superficial ulcers, more rarely sup- 
puration and abscess of the submucous cellular tissue. M. Louis 
found the former appearance in one-sixth of his cases. The gullet 
is likewise often superficially ulcerated — a very rare observation 
in other diseases at large. The slomach is sometimes enlarged ; 
softening, with attenuation of the villous coat, is common, having 
been found in a third part of Louis's cases ; ulceration, marked 
by a sharp eroded border, is more rare ; mammillated roughness 
very frequent ; and each of these states is often attended with 
grayness, bluishness or redness of the surface, which may also 
occur as the sole unnatural appearance. These anatomical cha- 
racters, which Broussais thought to be invariable, are very fre- 
quently altogether absent in the fevers of this country ; and M. 
Louis has given his valuable testimony to their not unfrequent 
absence even in what he considers the only true typhoid fever of 
France — the dothinenteritis of Bretonneau. The duodenal mu- 
cous membrane is at times red, softened, or even superficially 
ulcerated. The remaining small intestines are usually distended 
with gases, and contain a good deal of mucus, sometimes sangui- 
nolent, more frequently bilious. Their mucous coat is white in 
cases quickly fatal, red at a later stage, gray in old cases, and 
frequently softened ; but by far the most remarkable, and also 
(taking fever in the generic sense, as comprising continued fever 
of all countries), their most frequent morbid condition, is inflam- 
mation of the solitary and conglomerate glands, which are scat- 
tered over the course of the small intestines, and which especially 
abound near the ileo-cascal valve. The early stage of this organic 
affection consists of redness, thickening and softening of the glands, 
with sometimes a deposition of friable matter in the adjacent sub- 
mucous tissue. Afterwards the surface becomes bluish-gray or 
ulcerated ; and at a later period the ulcers are found to have 
spread, and sometimes put on a ragged, fungoid margin. Fre- 
quently a depression is seen, and over it a fine transparent pellicle, 
presenting the appearance of an ulcer which had healed. The 
isolated glands of Brunner are more rarely affected than the 
conglomerate glands of Peyer. Sometimes a perforation is seen 
at the bottom of an ulcer, together with the usual characters of 
peritoneal inflammation. The greatest amount of disease is com- 
monly found near the ileo-caecal valve ; and, in most cases, it is 
confined to the lower eighteen inches of the ileum. Ulceration 
is seldom observed, unless life has been prolonged beyond the 
fifteenth day of fever. The colon is, for the most part, distended 
with gases like the small intestines, and presents the same variety 
of structural derangements. In particular, the mucous cysts are 
frequently enlarged ; and ulceration is so common, according to 
Louis, as to be observed in a third part of the cases. 

[In all the cases reported by Dr. Gerhard, in the Philadelphia 



154 CONTINUED FEVER. 

epidemic of 1836, the mucous membrane of the stomach was 
more or less altered. The most common alteration was softening 
at the cardiac extremity; this was sometimes extensive; and 
sometimes limited to a small portion of the membrane. It varied 
in degree from diminished consistency to pulpy disorganization. 
All the coverings of the stomach were, in some instances, involved. 
A mammillated condition of the mucous membrane, especially 
towards the pyloric orifice, was not uncommon. In some cases 
there was blue engorgement of the large veins ; in some a pointed 
redness ; and in others a continuous dull slate colour of the mu- 
cous membrane. The intestinal canal was singularly exempt 
from any lesion ; occasional patches of ecchymosis being all that 
was observed. Of all the autopsies there was but one, where 
there was any deviation from the natural appearance of the glands 
of Peyer. In the case alluded to, in which there had been some 
diarrhoea, the agglomerated glands of the small intestine were 
reddened and a little thickened ; but there was no ulceration, and 
no thickening or deposit of yellow puriform matter in the submu- 
cous tissue. The disease of the glands resembled that sometimes 
met with in small-pox, scarlet fever, or measles, rather than the 
specific lesion of dothinenteritis. In all other cases, the glands of 
Peyer were remarkably healthy in this disease, as was the sur- 
rounding mucous membrane, which was much more free from 
vascular injection than it is in cases of various diseases not ori- 
ginally affecting the small intestine. The mesenteric glands were 
always found of the normal size, varying, as in health, from the 
size of a small grain of maize to three or four times these dimen- 
sions. With the exception of a slightly livid tint, common to 
them and the rest of the tissues, they offered nothing peculiar 
either in consistence or colour. The spleen was of the normal 
aspect, in one-half the cases ; in the other half, it was softened, 
but not enlarged, and in one case out of five or six, enlarged and 
softened. The liver was found sometimes moderately softened ; 
sometimes engorged with dark, fluid, oily blood, and sometimes 
spotted with ecchymosis. In many cases, however, it was the 
seat of no appreciable lesion. The contents of the gall-bladder 
differed in different cases : in some the bile was viscid ; in some 
it was thick, dark, grumous, and so on ; in others it was healthy. 
The kidneys, in some instances, were of a darker colour than 
natural, but commonly they were free from disease." 

In the cases examined by Dr. Shattuck, in the London Fever 
Hospital, the glands of Peyer, and the mesenteric glands were 
healthy. Of thirty-three cases examined by Dr. Reid, in the 
Edinburgh Infirmary, only two presented the follicular lesion, 
and these doubtfully. Dr. Villars, in a description of an epidemic 

* [Am. Journ. Med. Sciences, 1837,] 



ANATOMICAL CHARACTERS. 155 

typhus which prevailed at Toulon in 1833, positively asserts that 
the glands of the intestines were free from disease. Fleury, He- 
raudon, Pellicot,ui various publications hold the same language. 
Dr. Alison says, the complication, though rare in Edinburgh, is 
common in London.] 

3. The serous membranes seldom present distinct signs of 
disease. Serous effusion into the cavities, it is true, seems not 
uncommon ; but the amount is inconsiderable, and such as may 
well arise from pseudo-morbid operations. Louis met very rarely 
with either pleurisy or pericarditis ; and this is consistent with the 
observation of British physicians. Peritoneal inflammation is 
sometimes presented in the shape of redness and opacity of the 
peritoneum, lymph spread over it, and sero-purulent matter in its 
sac ; but this condition is extremely rare, except in consequence of 
perforation of the intestines by an ulcer from within. 

4. The glandular system is frequently affected. The sub- 
cutaneous lymphatic glands sometimes present induration and 
enlargement, and most frequently in the neck and axilla. These 
bodies, however, are, on the whole, seldom materially diseased 
comparatively with the lacteal and lymphatic glands of the abdo- 
men. The lymphatic glands of the stomach are at times enlarged, 
as also occasionally those which lie adjacent to the biliary ducts. 
The mesenteric glands are always more or less affected, wherever 
the mucous glands of the intestines suffer. The earliest marks of 
disease are some enlargement, or friability, and pale redness; at a 
more advanced stage there are greater enlargement and dark red- 
ness ; and at length, in the most advanced cases, the glands are 
filled with pus. The mesocolic glands are subject to the same 
pathological alterations. Sometimes both the mesenteric and 
mesocolic glands are diseased, where the intestinal mucous glands 
are healthy. 

Of the great viscera, the spleen is very generally found much 
softened, of a dark bluish-black colour, and much enlarged. The 
liver is more rarely enlarged, softened and friable, with unusually 
fluid bile, and at times redness of the lining membrane of the gall- 
bladder. The kidneys are at times softer, and darker than usual, 
and the bladder red internally. The heart is often dark, dry and 
softened, occasionally to such a degree as to be easily torn, and to 
retain, like dough, the impression of the fingers ; its cavities con- 
tain usually little blood, and, whenever its parietes are softened, 
the blood is in loose clots, without separation of fibrin or fluid, 
and mixed with air-bubbles. This condition of the heart always 
corresponds with a hurried, feeble, fluttering pulse during life. 
The lungs are frequently quite healthy, sometimes partially gorged 
with red serum, or partially hepatized ; the bronchial tubes usually 
contain a good deal of mucous fluid, and are dark-red in colour; 



156 CONTINUED FEVER. 

and the epiglottis, glottis and larynx occasionally show redness 
and thickening of their lining membrane, but very rarely erosion 
or ulceration. 

The secondary morbid appearances, of which the preceding 
narrative presents a succinct list, are derived principally from the 
able pathological directions of M. Louis, who is universally ac- 
knowledged to have given the best view of the pathological ana- 
tomy of the disease as it occurs in Paris. His account corresponds 
closely with the descriptions lately given of that variety of the 
London typhus, which is complicated with affections of the bow- 
els, and which will be found fully described in the writings of Drs. 
Bright, Tweedie, and Burns. 

The multifarious appearances of organic derangement thus in- 
dicated are, however, by no means common to all fevers, or even 
to all forms of typhus. On the contrary, very many instances of 
true typhus are to be met with even in London, where no marked 
morbid alteration of structure is to be seen at all, further than the 
signs of congestion or of immaterial serous effusion. As to the 
fever which has prevailed in Edinburgh for twenty years past, 
and in which serious bowel affections are in general very uncom- 
mon, it is certainly rare to witness any of the more prominent 
appearances so frequently seen by M. Louis and his countrymen. 
Even where signs of local disturbance of function existed during 
life, it is rare to observe distinct structural changes after death ; 
turgescence of vessels, and serous effusions to a limited extent, are 
the only general appearances ; an unusual accumulation of mucus 
in the bronchial tubes is not uncommon ; and, in a few instances, 
redness and effusion of lymph have been observed on the pleura. 
In particular, it is rare to find any unnatural condition of the in- 
testinal mucous membrane, so constantly observed in France ; fre- 
quently the entire tract of the alimentary canal is quite healthy; 
and the only appearances at all familiar, are various forms of red- 
ness, sometimes with softening, gray discoloration, and attenua- 
tion. The various remarkable appearances of softening of the 
viscera, indicated by M. Lours as of frequent occurrence, are here 
extremely rare. It seems reasonable to conclude, that the signs 
of structural derangement, ascribed by M. Louis to typhoid fever 
generally, are most of them peculiar pathological states, second- 
ary not to fever in general, but to one of its secondary disorders 
— inflammation of the mucous glands of the intestines. 

The most interesting of these structural derangements is un- 
doubtedly the softening, which is invariably observed in one or 
more of the great viscera in all cases where life is prolonged for 
a moderate number of days. It is a secondary or consecutive 
affection, is seldom observed until the intestinal disorder has had 
time to develop itseiffully, and is most marked in the cases where 



CAUSES. 157 

that disorder has advanced to suppuration and ulceration. Its 
precise nature is not ascertained ; but M. Louis is convinced it 
has no connection with inflammation of the structures it invades \ 
for, indeed, the organ which presents it, is generally softened 
throughout and equably, and does not show any one of the fami- 
liar pathological characters of inflammation in other circum- 
stances. It is the frequent cause of death, especially when it 
invades the heart; and the symptoms it produces are those of 
extreme depression of the circulation, and typhoid exhaustion. 



VI. CAUSES. 

One of the most melancholy proofs of the uncertainty of medi- 
cal doctrine, is the doubt still entertained by many estimable 
members of the profession respecting the causes of fever. Op- 
portunities of investigation have for many centuries abounded to 
a greater extent, perhaps, than upon any other question in medi- 
cal science ; the most eminent authorities in medicine have em- 
ployed these opportunities with zeal and acuteness ; and, never- 
theless, in the most enlightened parts of Europe, a division of 
opinion prevails on some most essential departments of the subject. 
But, after all, this division of sentiment arises as much from the 
different conformation of the human mind, as from any obscurity 
or contrariety of the facts. The peculiar sentiments of some have 
indeed been formed from peculiar opportunities of observation, 
from the observation of anomalies, which they have incorrectly 
regarded as the general rule. Yet it must be admitted, that the 
greater proportion of the discrepant doctrines of the present day, 
as to the origin of fever, are founded essentially upon the same 
great body of facts. 

While these discrepancies must be admitted and deplored, it 
does not appear that they are altogether so important or so dis- 
creditable to the reputation of physic as its maligners will insist. 
For the opinions of the great majority of scientific physicians are 
in accord on most of the essential points of doctrine ; and the de- 
viations occasionally observed should be regarded as in no respect 
different from the occasional dissents which take place every day 
in the conclusions formed by juries on questions of common life, 
which to most minds seem free of all ambiguity. 

, The great questions involved in the investigation into the causes 
of continued fever are three in number : — Does the disease ori- 
ginate in infection ? Does it originate in other causes ? Granting 
that it does originate in other causes, may such fevers propagate 
themselves by infection ? These questions will be considered in 
the order here laid down. It will be seen that they cannot be all 
answered by any means with equal confidence. 



158 CONTINUED FEVER. 

1. Infection. — By far the most important question relative to 
the causes of fever regards its origin in infection, or contagion. 
As these terms are used in various senses, it may be well to ob- 
serve, that, in the following remarks, contagion will be used in 
the sense of communication by contact, and infection in that of 
communication by the medium of effluvia or atmospheric poison. 
But indeed the former term may be discarded at once from the 
inquiry, with the simple statement that there is not a vestige of 
evidence to prove that actual contact is necessary for the trans- 
mission of any one febrile disease from the sick to the healthy — 
least of all, certainly, for the transmission of continued fever. 
Nor is it easy to see how anything like certainty, or even a strong 
presumption, is to be attained to on such a question. Science 
would gain by the abandonment or limitation of both terms now 
in use, and by the adoption of the generic term " communication," 
to denote the mere passage of disease from the sick to the healthy, 
without involving at all the question, in what way the passage is 
accomplished. 

In the British Islands probably not above one physician in fifty 
entertains any doubt of the infectious nature of continued fever. 
In France, and also in Germany, on the contrary, the opposite 
doctrine is at the present time prevalently adopted, though not 
by so preponderating a majority. It would be desirable to fix, 
if possible, the causes of so singular a discrepancy of sentiment 
and to find out whether the disease really differs in its characters, 
or the difference lies only in the disposition of men's minds. 
But such an inquiry would lead to a long argument, which 
would be misplaced in a work like the present. It must suffice 
then to set out with stating the general proposition, that the Bri- 
tish doctrine seems well founded in respect of the fever which 
prevails in Britain and Ireland, and to attempt establishing this 
doctrine by irrefragable facts. , 

Great advantage will be derived from conducting this inquiry 
with reference to bodies of men, rather than to solitary cases, on 
which the supporters of the doctrine of communication have 
been often too prone to rest their cause. Individual cases, how- 
ever conclusive to appearance, are open to many sources of fal- 
lacy, which it is impossible to guard against so thoroughly as to 
avoid the risk of error — much less to overcome the hesitation of 
over-cautious or reluctant understandings. Facts derived from 
groups of cases come with a force which no reasonable mind, 
however sceptical, can honestly resist. The arguments to be 
stated upon this principle will be drawn chiefly from direct per- 
sonal observation of the fever of Edinburgh for many years 
past. Equally pointed facts might be obtained from the history 
of epidemics of fever in other large towns. But perhaps they 
have never been ascertained with such precision, or under cir- 



CAUSES. * 159 

cumstanees so favourable for securing their conclusiveness, as in 
Edinburgh during the twenty years subsequent to the first great 
eruption of fever in 1817. 

The first argument in favour of infection may be found in a 
general survey of the history of fever in a district for a con- 
siderable term of years. In the rural part of the district it is 
seen to be always comparatively rare, and scarcely ever, pro- 
perly speaking, epidemic ; while in large towns it is never en- 
tirely absent, and often puts on the form of a wide-spread pesti- 
lence, which extends its ravages wherever human beings are 
most crowded together, and most exposed to breathe a confined 
atmosphere. When it becomes epidemic in a large town, it 
never bursts forth with impetuosity, like diseases of undoubted 
miasmatic origin ; but extends gradually, and always the more 
slowly the larger the city, so that many months may elapse be- 
fore it reaches its full height. In this condition it remains only 
for a limited time, the length of which is proportioned to the size 
of the city, and governed by the circumstance that a certain mo- 
derate proportion of a population is at any one time susceptible 
of infection, so that the disease must at length exhaust the con- 
stitutions liable to invasion. It consequently then begins to de- 
cline, retires as gradually as it commenced, and finally resumes 
its natural conditiqn, affecting only a few individuals here and 
there, and at distant intervals. A calm succeeds, and fever is 
almost forgotten. But in a few years its favourite haunts are 
occupied by a fresh population, with many susceptible constitu- 
tions. Under favour of co-operating circumstances it again 
emerges from obscurity to resume its epidemic devastations, and 
passes a second time through the same cycle of changes, and 
commonly in the same interval of time. In these successive 
revolutions no connection can be traced with season, tempera- 
ture, moisture, winds, barometric pressure, or any appreciable 
atmospheric condition. This general history, even excluding 
details, appears irreconcilable with any other supposition, than 
that the disease is transmitted by communication from the sick 
to the healthy. 

But secondly, on entering into the details of a particular epi- 
demic, new arguments of great weight may be obtained from the 
general history of its progress. Thus fever is found to spread 
at first, not by scattered unconnected cases occurring at a distance 
from one another, but by slow degrees around one or more in- 
vaded localities as foci— first creeping from one individual to 
another in a family, then from family to family, according to 
their proximity, relationship, or general intercourse, and at length 
to the surrounding population promiscuously, with the exception 
of the better ranks. It may often be difficult to trace out these 
facts with accuracy, partly on account of the great length of 



160 CONTINUED FEVER. 

time the infection often lies latent before the disease breaks forth, 
partly by reason of the apathy of the order of society where 
chiefly it prevails, and their natural forgetfulness of what is 
passing even in their immediate vicinity. But at the beginning 
of an epidemic, before the question is complicated by the esta- 
blishment of secondary foci for the disease, it may be always 
ascertained, with proper pains, to spread gradually to the neigh- 
bourhood of the sick in the first instance. 

But a further argument of very great weight may be drawn 
even from the very violations of this general rule. For some- 
times the disease is seen suddenly to arise, and gradually to 
spread, in parts of a town where it had not previously existed ; 
and this in concurrence with the arrival of the disease by im- 
portation from a previously invaded locality. It may indeed be 
objected, that the new eruption of the disease is merely an acci- 
dental coincidence with the communication which has been 
held with the invaded locality, and not its real consequence; 
that this constitutes nothing more than one of the solitary or 
individual facts, which were admitted above to be fallacious. 
But then there are instances where, after direct simultaneous 
communication with the disease in an invaded locality, several 
new foci are established at one and the same time; — a concur- 
rence which can scarcely be supposed to be the result of acci- 
dental coincidence, because, according to the doctrine of chances, 
it is in the highest degree improbable. Or, instead of several 
simultaneous foci being formed by the communication of several 
individuals at the same time with the disease at a distance, there 
may be several established consecutively in new and remote lo- 
calities by the same individual, passing from place to place while 
ill of fever — a conjunction of circumstances which is not less im- 
probable as the result of accident merely. Pointed facts of both 
these kinds have been selected by Dr. Alison (Edin. Med. 
Journ., xxviii. 233), and might be encountered much more fre- 
quently towards the commencement of an epidemic, if observers 
were to carry on their investigations with a more thorough know- 
ledge of the nature of evidence than is usually brought to the 
inquiry. 

A fourth argument, more powerful perhaps than any other, 
and upon which alone the doctrine of the communicability of fever 
might be rested, is, that in circumscribed localities inhabited by 
crowded bodies of men, fever is observed- invariably to spread 
among the healthy, when it is introduced to a great extent from 
without, but never materially at any other time. This is a general 
mode of expressing the history of such institutions as infirmaries 
and fever hospitals. During the last twenty years the Infirmary 
of Edinburgh has been made the receptacle of a large propor- 
tion of fever cases in three epidemics, which have lasted between 



CAUSES, . 161 

three and four years ; and there have been two intervals varying 
from three to five years in duration. During the intervals when 
fever cases from without were few, fevers originating within the 
hospital were extremely rare among any classes of individuals 
attached to its service. But during the prevalence of the several 
epidemics, fever abounded in every department of its service : 
physicians, clinical clerks, general servants, nurses, washerwomen, 
apothecary's assistants, all suffered more or less, and some to an 
excessive degree. The same facts were observed even more 
remarkably in an institution, which was, during the same interval, 
occasionally occupied as a fever hospital. In three epidemics it 
was made use of for this purpose ; and, at various periods during 
the last twenty-five years, it has also been occupied, when fever 
did not prevail epidemically in the city, by crowded bodies of 
men, first by soldiers as a barrack, then as a retreat for some 
hundreds of poor people who were turned out of their houses in 
the winter by an extensive fire, next as a quarantine house dur- 
ing the prevalence of cholera, and, for some years past during the 
worst epidemic of fever which has yet prevailed in this city, it 
has been occupied by about 300 of the very lowest of the com- 
munity, namely, as a house of refuge for vagrants and other 
destitute persons, Now, on each occasion when it was occupied 
as a fever hospital, the people on service in the institution suffered 
to an extraordinary degree, scarcely a single individual escaping 
an attack who remained a moderate length of time in it. But, 
on other occasions, fever was either absolutely unknown, or the 
cases were rare and distant, and easily referable to the particular 
manner of life of the individuals composing the population of the 
establishment. It is also worthy of notice, in reference to both 
chains of facts here mentioned, that neither around the infirmary, 
nor around the late fever hospital, did fever ever prevail to any 
material extent during any of its epidemic visitations. These 
remarkable facts seem to set at rest the question which has been 
agitated by some bigoted non-contagionists, Whether the preva- 
lence of fever in such circumstances may not be owing to some 
very peculiar circumscribed miasma? For here the local miasma 
must be held to be circumscribed by the very foundation-walls of 
the buildings, to affect those buildings alone of the numerous in- 
stitutions of a similar kind throughout Edinburgh; to be developed 
by fortuitous coincidence on three or four successive occasions, 
when fever patients happened to be brought in numbers into 
them ; and to be cleared away by the same incomprehensible 
accident on repeated occasions, exactly when fever cases cease 
to be accumulated from without. How any individual in the 
possession of understanding, and aware of the import of evidence, 
can resist such proofs as these, and continue to deny that fever is 
communicable, appears utterly incomprehensible, unless he call 
11 



162 CONTINUED tfEVEE. ' 

in question the special facts ? These, however, are familiar to 
hundreds. It would be out of place to detail them numerically 
here ; but a part of them may be seen in the statistical form in the 
paper of Dr. Alison already quoted. 

The fifth and last argument, and one little inferior in force to 
that just laid down, is, that in hospitals where fever patients 
abound, the proportion of attacks among the people on service is 
in the ratio of their exposure to the emanations from the sick, 
Nurses are most exposed, and accordingly surfer most; in Edin- 
burgh not a single fever nurse escapes who remains long enough 
at her post. In 1818 Dr. Welsh, then superintendent of the 
Fever Hospital, found that of thirty-eight nurses all were attacked 
excopt two or three, who had been but a short time in the insti- 
tution, (On Blood-letting" in Fever, p. 45,) — a statement which 
the writer is able to confirm, having at the time been a resident 
clerk. Next in order came the resident clerks or house surgeons^ 
who have charge of fever cases, and whose peculiar risk consists 
in their duties calling them to make minute personal examinations 
of the patients at all times, but especially on their first admission., 
and generally to spend much time in the atmosphere of fever 
wards. Accordingly few of them escape fever long. Of fifteen 
gentlemen, who held between 1817 and 1820 the offices of house- 
surgeon, or resident clerk, in the Edinburgh Infirmary and Fever 
Hospital, two only escaped an attack; and during seventeen 
months of the period, when the epidemic was at its height, there 
occurred sixteen cases of fever among ten of these, of whom five 
had it once, four twice, and one thrice. The third rank in point 
of exposure may be assigned to dressers and house-servants, who, 
according to the practice pursued in Edinburgh, are not much in 
communication with fever patients, but who, when this does oc- 
cur, communicate with them closely. The proportion of seizures 
in this class is much less than in the two former, but still quite 
sufficient to attract observation, as distinguishing them from those 
whose exposure is still less. The precise number it is unfortu- 
nately impossible to ascertain. The next place may be assigned 
to the medical students of hospitals, not attached to the service of 
the institution. Here the exposure is for the most part insignificant, 
because few general students examine the cases of fever with 
minuteness: accordingly few suffer. In the early epidemic of 
1817-20 in Edinburgh, when the resident clerks suffered so severe- 
ly, fever was absolutely unknown among the general class of 
hospital pupils, because at that time the disease was new as an 
epidemic, and held in wholesome dread ; so that the physicians of 
the infirmary were commonly deserted in their rounds, when they 
arrived at the doors of the fever wards. Now, however, fever is 
a more familiar visitor ; the fever wards and fever patients are 
approached by most without hesitation, and by some the cases 



GAtJSES. 163 

are examined with care and minuteness. Accordingly a few in- 
stances of fever are every now and then presenting themselves in 
the present class, but nevertheless far fewer proportionally than 
in any other denomination of persons yet mentioned. In the win* 
ter of 1836-7, among sixteen gentlemen in charge of the general 
and fever patients of the university clinic, there occurred nine 
cases of fever ; while among their fellow-students of clinical me- 
dicine, 140 in number, who had no particular charge, there were 
only four attacks. In conclusion, and in contrast to all these cir- 
cumstances, may be taken the condition of other bodies similarly 
situated in every other respect, except that they are not exposed 
at all to the concentrated fevers of a hospital. And, to avoid all 
ambiguity, let the attention be confined to such as occupy the 
same station of life, and follow the same pursuits with those who 
have been seen to be so very liable to fever under exposure, 
namely, to medical pupils not in attendance upon any hospital 
where fever cases are collected together. Here the chain of evi- 
dence is found to constitute an uninterrupted succession of links. 
In 1817-20, when the disease prevailed so extensively among the 
few medical pupils attached to the service of the hospitals, it was 
wholly unknown among seven or eight hundred medical students, 
who did not come in contact with fever ; and in 1836-7, when it 
occurred severely among clinical clerks, and to a slight degree 
among the general clinical pupils, on the most careful inquiry it 
was ascertained that among 500 or 550 medical pupils, not clini- 
cal, only two cases had occurred in six months, both of whom 
were much in contact with fever in the houses of the poor in the 
capacity of pupils to a public dispensary. 

Little doubt can exist, that the history of other hospitals and 
other schools might furnish similar facts equally interesting and 
not less conclusive. But there are circumstances in regard to the 
institutions of Edinburgh, which it is needless to dwell upon, and 
which tend to place the evidence of such general facts in a very 
strong and unequivocal light. Other general facts of the same 
nature might be drawn from the experience of the Edinburgh 
hospitals. It may be sufficient to mention two only. It has been 
invariably remarked, that 'the admission of a few fever cases into 
a general ward is attended with little or no risk of the fever pass- 
ing to the other inmates of these wards. But so soon as the cases 
exceed considerably a third of the whole, then the fever begins to 
show itself among the domestic attendants, and to appear among 
the other patients. And if a convalescent from some other fe- 
brile disease is allowed to remain in a fever ward, he is attacked 
with fever almost invariably. The only other general fact of the 
same purport requiring mention is, that in a pure fever hospital 
extremely few of the inmates of any denomination escape. This 
fact has been adverted to in a former statement. 



164 CONTINUED FEVER. 

Laws op Infection. — The communicability of fever from the 
sick to the healthy being thus put beyond all possibility of ques- 
tion, it becomes an object of great consequence to determine the 
rules by which its communication is governed. A good deal of 
vague statement has been published on this subject; and the laivs 
of contagion, as they have been boldly designated, have been 
promulgated with considerable confidence. Much fallacy and 
error, however, have crept into the inquiry towards determining 
these rules, partly because too much reliance has been placed on 
conclusions drawn from solitary facts occurring in the instance of 
single individuals, and partly because various communicable or 
infectious diseases have been mingled together in the investiga- 
tion. Confining the attention to continued fever, as it appears in 
the British Isles, the following general propositions seem well 
established : — 

1. All the forms of primary continued fever are communicable, 
and probably in an equal degree. It is generally thought that 
synocha, or pure inflammatory fever, is an exception ; and even 
some unhesitating contagionists incline to this opinion. Such cer- 
tainly seems to be the case in hot climates ; and such seems pro- 
bably also the fact with the ephemeral synocha of temperate coun- 
tries. But there can be no manner of doubt, that the inflammatory 
fever described above, as prevailing with synochus and typhus in 
the epidemic form, is capable of being transmitted from the sick to 
the healthy. It was seen to do so unequivocally in Edinburgh 
between 1817 and 1827, when it was at different times prevalent, 
one type of fever seeming to produce all types indiscriminately. 
In a considerable proportion of the resident clerks of the hospitals, 
the disease assumed the pure inflammatory form ; and the same 
fact was also observed, though not to so great a degree, in the in- 
stance of young adults generally. 

[The contagious nature of the epidemic fever of Scotland dur- 
ing 1843, was not doubted by any of the writers of the various 
notices of it; and numerous and satisfactory proofs of this fact 
are recorded by them.] 

2. Very great differences exist between different individuals, as 
to their liability to fever under exposure to it. Some are seized 
soon after slight exposure, others only after several months of 
close communication with the sick, and a few seem proof against 
infection altogether. The experience of fever-hospitals, however, 
in epidemic seasons, renders it probable, that the immunity appa- 
rently enjoyed by some is only relative, and not absolute ; for it 
has been seen above, that in a fever hospital during an epidemic 
every individual without exception is seized, sooner or later, who 
remains long in the establishment. Continued fever, therefore, is 
probably communicable to all constitutions. 



CAUSES. 165 

[Why healthy individuals, well fed, and cleanly,are more suscep- 
tible of contagion at one period than another, is totally unknown. 
Vaccination sometimes succeeds after four or five unsuccessful 
trials; and unprotected physicians may pass through several epide- 
mics of scarlet fever or measles, unscathed, and yet finally contract 
the disorder. Dr. Bancroft says, " that among ninety-nine order- 
lies and nurses who had probably not been exposed to the conta- 
gion before their attendance on the sick commenced, the earliest 
attack was on the 13th day, and the latest on the 68th; but these 
returns were made up on the 20th of April, and it appears that 
some who had escaped at that time were afterwards attacked ; 
and therefore, though there may be reason to conclude that febrile 
contagion does not remain inactive so long after being received 
into the body as marsh miasmata, I see none for believing that an 
interval of five or six months may not sometimes elapse before 
the actual production of fever by it."* Dr. Perry is of opinion 
that the earliest period of the disease making its appearance after 
exposure to contagion is eight days, more frequently fourteen, and 
sometimes so long as two months.t Dr. Barker says that the 
latent period of the contagious principle seems to extend to two 
or three weeks. 

Dr. Tweedie notices the exemption of butchers from fever, 
and states that though almost every description of mechanics was 
admitted during the year into the London Fever Hospital, he did 
not recollect of a single instance of a butcher.! Other physicians, 
however, have met with patients who followed this occupation. Dr. 
South wood Smith, in his table of the occupations of 679 patients 
affected with fever, enumerates three butchers, two curriers, and 
two skinners. § Dr. Craigie, in his table of 181 cases of fever 
treated in the Edinburgh Royal Infirmary, mentions three butch- 
ers among that number. || 

Persons affected with chronic disease of the chest or abdomen, 
seldom contract with typhus. Hildenbrand says, that phthisical 
persons are rarely attacked with typhus. Dr. Davidson states, 
that of 100 post-mortem inspections of fever, he had met with 
only three cases of tubercles; and that their number in each did 
not exceed three, which were small and only partially softened. 
J. Frank, on the contrary, places phthisis among the predisposing 
conditions. Facile suscipiunt qui febribus intermittentibus, 
phthisi pulmonali, scorbuto et syphilide laborant, (Praxeos 
Med.,t. iv. p. 98) — are his words. With respect to scurvy, Dr. Bou- 
din maintains that it is a preservative against typhus, and relates 

* [Bancroft on Yellow Fever, p. 516.] 

f [Ed. Med. and Surg. Journ., vol. xlv. p. 69.] 

i [Tweedie's Clinical Illustrations of Fever, p. 79.] 

§ [Southwood Smith's Treatise on Fever, p. 431.] 

j [Edinb. Med. and Surgical Journal, vol. xlvii. p. 286.] 



166 CONTINUED FEVER. 

several facts, which go far to sustain his opinion. He states that, 
after the battle of Navarino, on board the hospital ships, the only 
persons who escaped the fever, were those labouring under scurvy. 
Lind (Jin Essay on the means of preserving the health of sea- 
men. London, 1774, p. 195), expresses the same opinion, and 
mentions an instance strongly confirmatory.] 

3. The infection of continued fever is for the most part by no 
means virulent. This is contrary to universal prejudice among 
unprofessional persons, and to the opinion entertained even by 
some members of the medical profession. But it is nevertheless 
certain — so far as minute observation of several violent epidemics 
during the last twenty years can determine the point — that mode- 
rate precautions will render the infectious atmosphere inert. 
Cleanliness and ventilation will speedily extinguish any epidemic. 
For it is well ascertained, that fever communicated to an indi- 
vidual in the better ranks by attendance on the sick in hospital, is 
very rarely propagated in his own station, or to any of his attend- 
ants. Among numerous instances known to the writer, of young 
practitioners and medical students who have caught fever in the 
prosecution of their practical studies, not a single case has oc- 
curred where the disease was communicated in their families at 
home or in their lodging-houses. 

[The contagious matter is readily diffused through the air, and 
loses its poisonous quality by dilution, so that, at a distance of 
twenty or thirty yards, air which has passed over the bodies of 
persons ill of continued fever, is innocuous.] 

4. On the other hand, infection operates with very great certainty 
wherever cleanliness and ventilation are neglected. Hence the 
ravages it commits among the poor. Hence, especially, the 
extraordinary devastations it commits among the low lodging- 
houses of great towns. Even in the better ranks of society, the 
same co-operating causes will make it spread. In an instance 
where the disease was introduced into a family in good circum- 
stances, the mistress of which was slovenly and a fatalist in her 
notions, no fewer than seven children were attacked in succession 
in the course of six weeks. 

[Filth and deficient ventilation tend powerfully to spread the 
contagion of typhus ; where it is concentrated, as in hospitals, or 
in the small, ill-ventilated houses of the poor, it rarely fails to be 
communicated to the unprotected attendants, or inmates. Per- 
sonal filthiness, though doubtless rendering the morbid effluvia 
more contagious, does not exercise, by any means, as decisive an 
influence as deficient ventilation. Dr. Bateman, after describing 
the method to be adopted for promoting cleanliness and sufficient 
ventilation, remarks : — " During the fourteen years, in the course 
of which I have almost daily been in contact with persons labour- 



CAUSES. 167 

ing under contagious fever, not only myself, but all the nurses, 
have thus been preserved from infection, with one exception, 
down to the period of the present epidemic." He adds in a note : 
" It is no disparagement to the system above described that some 
of the nurses and the matron of the House of Recovery have been 
infected during the present epidemic, which has kept the wards 
constantly full. The impossibility of maintaining a free ventila- 
tion night and day, during the cold weather, their perpetual 
exposure, in close contact, to the breath and discharges of the 
patients, while feeding, moving, or washing them, changing their 
beds and linen, and even stripping off their infected clothes on 
admission, might be sufficient to counteract the solitary operation, 
of any general system, however efficacious. But the truth is, that 
the ventilation of the house has been very imperfect, and even at 
the command of the nurses and patients; and the injurious conse- 
quences of this imperfection have become so manifest, that the 
subject is now under the consideration of the committee, while 
this work is in the press."* Dr. Hancock quotes the following 
facts, which illustrate very powerfully the influence of ventila- 
tion :— -" In the year 18J.9, 1 had occasion to see a very intelligent 
physician, connected with one or two fever hospitals in Dublin, 
during the epidemic, who assured me he had seen no proof of the 
existence of contagion in the disease (typhus) as it appeared in 
those institutions under his care, where very great attention was 
paid to ventilation, and where the patients were not inconve- 
niently crowded. But soon after this, I saw another physician 
no less intelligent, who informed me that in the course of about 
four months, between 200 and 300 persons were admitted into 
the Belfast Fever Hospital; and they were frequently so crowded 
in the wards as nearly to cover the floor with their beds ; in which 
case, although the building is new, airy, and well regulated, the 
matron, twenty-two nurses, and the apothecary took the disease ; 
yet it was so mild, that scarcely more than one in fifty died."t 
Dr. Pric hard relates a striking example of the effects of a good 
as well as of a deficient ventilation, which occurred in two of the 
hospitals in Bristol, namely, St. Peter's and the Bristol Infirmary; 
both of these institutions being under his medical superintendence. 
"In the former, (St. Peter's,) the medical wards are very small, 
and it was necessary to place the beds very near to each other, 
and to put too great a number of patients in a given space. 
Offensive smells were often perceptible ; and it was under these 
circumstances that the disease was manifestly contagious." In 
the Bristol Infirmary the wards are lofty and well ventilated. 
Here, also, the fever patients were dispersed among invalids of 

* [Batematt on Contagious Fever, p. 154.] 
f [Hancock on Besiiience, p, 339.] 



168 



CONTINUED FEVER, 



almost every other description. But no instance occurred of the 
propagation of fever; none of the nurses were attacked, nor were 
the patients lying in the adjacent beds in any instance infected, 
though cases of the worst description of typhus gravior were 
placed promiscuously among the other patients, scarcely two feet 
of space intervening between the beds.* Drs. Barker and 
Cheyne relate another remarkable proof in Sir Patrick Dunn's 
Hospital of a ward, by the peculiarity of its construction, pro- 
tecting the attendants upon the sick from the effects of contagion. 
Drs. Barker and Cheyne remark, in that portion of their report 
which has been already quoted, that typhus generally spreads in 
the families of the lower classes and very rarely in those of the 
superior ranks. Dr. Cowan states that " the fever was chiefly, 
nay, almost wholly, confined to the labouring classes and to the 
districts which they inhabited, while among the wealthy and 
middle classes of society it was comparatively seldom met with, 
and when it did occur, was not spread by contagion through all 
the inmates of the family, as was usually the case among the 
families of the poor, but was confined to a single individual."! 
These results, as stated by the above-mentioned authors, agree, 
we are convinced, with those which have been made in almost 
every other place. "This remarkable difference, in the two 
classes of persons referred to," says Dr. Davidson, " must be 
owing chiefly to the wide diversity of circumstances in which 
they are placed ; and approximates very closely to the difference 
which exists between a crowded, and, consequently, an ill-venti- 
lated hospital, and one 'which is limited to a small number of 
patients with thorough ventilation. The lower classes in large 
cities generally live in dirty ill-ventilated houses, and are often 
filthy in their persons ; while the better ranks live in more airy 
situations, have larger houses, and are more attentive to cleanli- 
ness in their persons and domestic habits ; hence the effluvium 
which issues from a typhus patient, in the first-mentioned situa- 
tions, cannot be carried off so readily, or diluted to the same extent 
with atmospheric air as in the second.''^ Dr. Marcet once col- 
lected a number of cases of typhus into one of the wards of Guy's 
Hospital, for the purposes of clinical instruction, when all at once 
the disease began to spread to other patients, and to the nurses, 
although it had not done so when the cases were distributed 
throughout the hospital, and it ceased to do so when they were 
again divided.] 

5. One attack of fever is in some measure a protection against 
subsequent communication of the disease. An erroneous notion 

* [Hancock on Pestilence. Prichard's History of the Fever in Bristol* jk 
• 88.] 

f [Cowan's Vital Statistics of Glasgow, p. 34»] 
4 [Thackery, Prize Essay, toe. cit.] 



CAVSES. 169 

has prevailed, that one attack is a complete defence ever after- 
wards; but numberless facts prove the contrary. The history of 
fever hospitals shows, that the same individuals are frequently 
attacked in more than one epidemic, or even twice in the same 
epidemic ; fever nurses very often have the disease twice at least; 
the writer of this article has had it six times while attending the 
fever wards of the infirmary or fever hospital ; and Dr. Tweedie, 
physician to the London Fever Hospital, has had it three times. 
Nevertheless, a majority of those who have had one decided 
attack referable to infection, are not liable to suffer afterwards ; 
and the protective influence of the first attack is even shown in 
some measure in the instances of those who do suffer a second 
time, by the longer exposure, which seems always necessary for 
the infection to take effect. 

[Typhus generally attacks individuals but once during their 
lives. The exceptions met with are occasional, and do not inter- 
fere with the truth of the general proposition. It is known that 
small-pox, measles and scarlet fever, which, it is conceded, attack 
individuals but once, sometimes return, especially at epidemic 
periods. Dr. Lombard, of Geneva, when describing the differ- 
ence between the continental and British typhus, says, that " in 
one remarkable point, however, I believe they agree, I mean the 
fact that no one is known, or at least is very rarely known, to 
have the eruptive typhus twice. With us such instances are 
scarcely if ever met with, and I am informed that with you a 
person once attacked with typhus, attended with the measles-like 
eruption, may safely calculate upon immunity from the disease 
for the future."* Dr. Perry, of Glasgow, declares, as one of his 
conclusions respecting typhus fever, that, "contagious typhus is an 
exanthematous disease, and, like small-pox, measles, and scarlet 
fever, during its course produces some change on the system, by 
which the individual having once undergone the disease, is (as a 
general rule) secured against a second attack, and may with im- 
punity expose himself to the contagion of typhus, if he continues 
to reside in the same country in which he previously had the 
disease. In those cases which are exceptions to the general rule, 
the disease appears in a mild and modified form, the crisis taking 
place on the seventh, ninth, or eleventh day." The same author 
remarks, that this conclusion as well as the others in his paper, are 
"the result of careful observation in upwards of 4000 cases."t Drs. 
Barker and Cheyne, who had the most extensive opportunities 
of ascertaining the history of typhus, seem to entertain opinions 
similar to those already quoted. They state that " at the hospital 
in Cork street, only one physician and the apothecary had an 

* [Dublin Journal of Medical Science, vol. x., p. 23.] 
f pEd. Med. and Surg. Journ., vol. *iv.. p, 67,} 



170 CONTINUED FEVER. 

attack of fever ; but then most of the physicians of the establish- 
ment had laboured under that disease on some former occasion, 
previous to the appearance of the epidemic."* Dr. Cowan, as 
already quoted, mentions that all the gentlemen who have acted 
as clerks in the Fever Hospital for many years past have been 
attacked with fever, unless they had it previously to their election. 
Hildenbrand's opinion on this subject is of a more modified 
kind. He observes that " the miasma of typhus, after having pro- 
duced the fever, destroys almost always, for a certain time, the 
susceptibility to a similar contagion ; nevertheless, it destroys it 
rarely for the whole of life, as do small-pox, measles, &c. It 
has, however, under this resemblance,.some analogy with the virus 
of these diseases, whilst on the contrary it totally differs from the 
syphilitic virus, which, when once introduced into the human 
body, always favours more and more a similar contagion."! 
The following table shows the answers to questions which were 
carefully put to patients who were admitted into the Glasgow 
Fever Hospital from November 1st, 1838, to November 1st, 1839. 
It includes the whole of the patients affected with eruptive typhus, 
from whom answers were obtained relative to any former affec- 
tion with fever, as evidence from decided cases only could be 
made available in the elucidation of this point : 





Males. 


Females. 


Total. 


Not previously affected 


284 


251 


535 


Previously affected 


33 


41 


74 



609 

" This table shows that out of 609 eruptive or decided cases of 
typhus, there were only 74 persons who stated that they had pre- 
viously laboured under fever. This part of the evidence may be 
reckoned positive ; for individuals of all intellectual capacities 
remember a remarkable circumstance of this kind. On the other 
hand, the evidence respecting the nature of the former fever or 
affection is the converse of this ; for only in a very few cases can 
it be correctly ascertained ; and when we take into account the 
various diseases which are confounded with typhus, (as shall be 
afterwards shown,) such as bronchitis, pneumonia, pleurisy, intes- 
tinal affections, febriculous or short fevers, and the numerous 
ailments of childhood, this small number can be satisfactorily 
accounted for. It appears, therefore, that the evidence which can 
be produced to bear on this point, although not very extensive, 
decidedly supports the opinion that eruptive typhus fever affects 
individuals, as a general rule, only once in their lives ; and it is to 
a considerable extent corroborative of this opinion, that almost all 

* [Barker and Chetne on Fever, vol. i., p. 135.] 

f [HlLDEKBRAIfD, p. 75,] 



CAUSES, 171 

the clerks and nurses of the Glasgow Fever Hospital for the last 
six or seven years have had typhus characterized by the eruption, 
and not one of them, as far as we have been able to learn, have 
ever had it since ; while almost all of them consider themselves 
now perfectly secure against a second attack, although constantly 
exposed to the effluvia arising from fever patients."* 

Dr. Perry, of Glasgow, in a letter to the editors of the Dublin 
Journal of Medical Science, says— "I have, for some years, enter- 
tained the opinion, founded upon an extensive series of observa- 
tions, that contagious typhus is an exanthematous disease, and 
is subject to all the laws of the other exanthemata ; that, as a 
general rule, it is only taken once in a lifetime, and that a second 
attack of typhus does not occur more frequently than a second 
attack of small-pox ; and, judging from my own experience, less 
frequently than a second attack of measles, or scarlet fever." Dr. 
Stoker speaks of the poor as having frequent attacks of fever in 
the course even of a short life, and thinks that few adults have 
escaped these attacks, although he has no doubt that the suc- 
ceeding attacks are milder than the first. Dr. O'Brien, in one of 
his hospital reports, says — "Some of the nurses have had the dis- 
ease three or four times." Dr. Barker is of opinion, that if the 
measly eruption is full, second seizures are very rare, and that the 
liability to these is less in proportion to the duration and severity 
of the first attack. Dr. Alison thinks, whilst the susceptibility is 
much diminished by a first attack, entire immunity is not con- 
ferred.] 

6. Fever is usually communicated by long exposure to the 
emanations from the sick, and seldom by any single short expo- 
sure, however decided. This general law seems to follow as a 
corollary from what was stated in the third section. It is a com- 
mon notion that single, brief, decided exposures often occasion 
an attack ; and, in support of this notion, reference is made to 
cases where individuals can trace the infection, as they imagine, 
to a particular fever patient, by having experienced some very 
peculiar morbid sensation at the time of exposure. There is 
much room for fallacy, however, in observations of this kind ; 
and, besides, their proportion is small, compared with the far more 
numerous instances where no such sensations can be recalled as 
having ever been experienced. That communication in this way 
must be extremely rare, is evident from unequivocal facts ; for, if 
short decided exposures could readily produce fever, how happens 
it that the disease is so very seldom propagated among the attend- 
ants of medical students and others of the better ranks who labour 
under it ? That the infection is communicated rather by frequent 
and long imbibition of the poison, will farther appear from the 

* [Davidson, Thackery Prize Essay, loc. cit.] 



172 CONTINUED FEVER. 

manner in which a previous attack confers partial protection sub- 
sequently. The common interval in the case of clinical clerks 
and nurses, between taking charge of fever patients for the first 
time and the breaking out of the disease, is three or four weeks. 
In the instance of a second attack the interval is about as many 
months, as if simply a longer draught and larger quantity of the 
poison had become necessary for the development of its influence. 
It seems probable, indeed, that a second attack of true infectious 
fever scarcely ever takes place, except under repeated and long- 
continued exposure. 

[Many interesting cases are mentioned by respectable authori- 
ties, however, where the disease manifested itself immediately after 
direct communication with infected persons. Sir Henry Marsh 
relates a great number of cases of this description,* and says that 
they are a few among many facts of the same kind, which he has 
been able to collect, and that every day's observation adds to their 
number. Most of these are cases of physicians or attendants on 
the sick, who, in the course of their duties, have been exposed to 
some strong offensive odour arising from the bodies or clothes of 
patients, and were immediately seized with the initial symptoms 
of the disease, which soon became fully developed. Drs. Craw- 
ford, James Clarke, and Waring died under such circum- 
stances. Dr. Gerhard relates two cases of the same kind, before 
alluded to (p. 104). The nurse was shaving a man, who died in 
a few hours after his entrance ; he inhaled his breath, which had 
a nauseous taste, and in an hour afterwards was taken with 
nausea, cephalalgia, and ringing in the ears. From that moment 
the attack of fever began, and assumed a severe character. The 
assistant was supporting another patient, who died soon after- 
wards ; he felt the pungent sweat upon his skin, and was taken 
immediately with the symptoms of typhus. Dr. Copland men- 
tions the case of a young lady, who went to visit an intimate 
friend, ill of fever, and having gone into the chanber was sensible 
of a disagreeable odour, on the curtains of the bed being with- 
drawn. She was soon afterwards attacked with the fever.] 

7. It is not improbable that, on an average, the severity of the 
disease bears some proportion to the amount of exposure. This 
point cannot easily be settled with any precision. But the affir- 
mative is rendered a reasonable presumption by the fact, that 
hospital nurses, clinical clerks, and others similarly exposed, 
undergo, with very few exceptions, a much more violent attack 
than the average. 

8. Individuals affected with other febrile and inflammatory 
diseases are not subject to invasion from exposure to fever so 
long as their primary disease continues ; but this protection ceases 

( « [Dublin Hospital Reports, vol. iv.] 



CAUSES. 173 

on convalescence being established, and probably even gives place 
to greater susceptibility. Hence patients with eruptive fevers 
may be safely kept in fever wards until the symptomatic fever 
subsides; but, when convalescent, they run very great risk of 
taking fever, if not speedily removed from such exposure. 

9. The infection of fever takes effect, on an average, more 
readily among those who are constitutionally infirm than among 
the robust. It is a great mistake to suppose, as some do, that 
robust and sound constitutions are little subject to be invaded by 
fever, if exposed to its cause. Numberless instances to the con- 
trary may be observed in every epidemic. But that the disease 
attacks with greater facility those of infirm constitutions is suffi- 
ciently apparent from the interesting and well-ascertained fact, 
that, during extensive epidemic visitations, it often seems, as it 
were, to swallow up other diseases. The general patients of 
hospitals in large towns become generally fewer in number, sim- 
ply because those, who, in other circumstances, would have suf- 
fered from disease at large, escape that fate by swelling the list of 
the epidemic devastations. 

[The opinion is a prevalent one among medical men, that weak 
and delicate persons are more liable to fever than the strong and 
robust. It is not capable of proof, however ; and is founded on the 
general assertion of authors. Dr. Davidson kept a record of 
the physical habit of the patients admitted into the Glasgow 
Fever Hospital from May 1st to November 1st, 1839, and the 
following were the divisions adopted : 

1. Moderate, by which is meant a person having an ordinary 
quantity of muscle and cellular substance. 

2. Full or plethoric, having an extra quantity of adipose tex- 
ture or of blood. 

3. Muscular. 

4. Spare. 

5. Emaciated or unhealthy in appearance. 

Males. 
Moderate - - - - - 116 

Full or plethoric - 28 

Muscular 44 

Spare - - 24 

Unhealthy or emaciated - 2 

429 

The whole of these 429 cases were characterized by the typhoid 
eruption, and will, therefore, be considered as decided cases of 
typhus. It appears from this table, that there were only 10 cases 
in an emaciated or unhealthy condition; and almost all of them, 
as far as could be ascertained, were engaged in their ordinary 
occupations at the time of their seizure. The spare and unhealthy, 



Females. 


Total. 


93 


209 


73 


101 


... 


44 


41 


65 


8 


10 



174 



CONTINUED FEVEIL 



when added together, only form about 17 per cent, of the whole 
number.] 

10. The infection of fever diminishes in effect as life advances. 
This general fact is universally admitted. It may be beautifully 
illustrated from the data supplied by Dr. Cowan for the epidemic 
of Glasgow in 1836. The following table combines the relative 
population in 1831, and relative fevers admitted into hospitals in 



1836, at different ages: — 














Age 


5 to 10 


10 to 15 


15 to 20 


20 to 30 


30 to 40 


40 to 50 


50 to 60 


above 60 


Population 
Fevers 


25,707 
191 


21,211 
318 


20,745 
501 


38,185 
715 


26,419 
309 


18,014 

128 


11,648 

43 


10,220 
11 



No correct inference can be drawn from this table in respect of 
children under fifteen, because the same proportion of the sick 
poor under that age, do not apply for admission i'nto hospitals as 
at other ages. But, from Dr. Cowan's data above that age, it 
may be calculated that, if the chance of seizure between fifteen 
and twenty be supposed to be 100, it becomes between twenty 
and thirty, in round numbers, 78 ; between thirty and forty, 49 ; 
between forty and fifty, 29 ; between fifty and sixty, 15 ; and 
above sixty, 4|. 

^During the epidemic at Philadelphia, in 1836, children were 
rarely attacked. After childhood, age seemed to exercise little or 
no influence upon the susceptibility of the disease. Amongst the 
whites, when the age could be more accurately relied on, there 
were as many patients under thirty-five as over that age. Dr. 
Geary, in his report of the Limerick Fever Hospital, states " that 
children are much more liable to fever than is generally supposed, 
and to the little apprehensiveness of disease being transmitted by 
them, may be attributed the spread of disease through families in 
many instances. It will be seen underneath that nearly one-sixth 
of the admissions for 1836 were under ten years of age, a fact 
which bears out what we have stated, and is also a satisfactory 
proof of the increasing confidence which public hospitals are 

acquiring from the community Of the entire treated 

for the year, full two-thirds were under twenty years of age."* 
A discrepancy will be immediately observed between the con- 
clusions of Dr. Cowan and Dr. Geary. It must be shown that 
the admissions of cases into hospitals are in the same proportion 
as to ages as that which existed amongst the population from 
which they were sent. Dr. Arthur Thompson compiled the fol- 
lowing table to remedy this defect : 

* [Dublin Journ. Med. Sci«, vol. xii., pp. 98, 99.] 



CAUSES 



175 



Table showing the estimated number in the inhabitants at Glasgow at each age dur« 
ing the year 1836 • the number attacked by fever, together with the ratio attacked 
out of every thousand at each decennial period of life. 



Ages. 


No. of inhabitants 


No. attacked by 


Ratio per 1000 at- 




at each age. 


fever. 


tacked by fever. 


Under 10 


67-469 


3811 


56 


10 to 20 


50-009 


1539 


30 


20 to 30 


46-275 


1611 


34 


30 to 40 


32044 


911 


28 


40 to 50 


21-758 


392 


17 


50 to 60 


14-090 


294 


20 



It appears from this table that the greatest susceptibility to 
fever occurred under ten years of age, after which fever occurs 
most frequently among persons between the age of twenty and 
thirty. The number attacked after the age of thirty decreases 
gradually as life advances.* Into the Glasgow Fever Hospital 
there were admitted, during the year 1836, 2257 cases of fever 3 
and out of this number there were 41 under five years of age, 
and 3 between seventy and seventy -five years.t Into the Limerick 
Fever Hospital, during the year 1836, there were admitted 3227 
cases of fever, and there were 81 below five years of age, and 10 
between sixty-five and seventy years.J Dr. Craigie treated in 
the Edinburgh Royal Infirmary 7 cases of fever between sixty 
and seventy years, among 343 admissions.§ Dr. Davidson states 
that he has met with, in the Glasgow Fever Hospital, 5 cases of 
eruptive typhus in children reported to be three years of age, from 
the 1st May to 1st November, 1839. Dr. Barker, in the course 
of the epidemic of 1817, '1 8 and '19 in Ireland, witnessed the 
disease in many children under the age of four or five.] 

11. The sexes seem equally exposed to receive infection. In 
the Glasgow epidemic of 1836, among 2260 cases 50-5 percent, 
were females, and 49*5 males. In the Edinburgh epidemic of 
1819, of nearly 1600 patients 57 per cent, were females, and 43 
per cent, males. The slightly superior liability of the female sex 
is probably owing to their greater exposure as attendants of the 
sick. 

[The facts hitherto published regarding the susceptibility of the 
sexes to fever, are not sufficiently extensive to warrant any posi- 
tive deductions. So far there is no positive evidence that one sex 
is more liable to the disease than another. " The number of 



* [Edinburgh Med. and Surg. Journ., July, 1838, p. 92.] 

f [Cowan's Vital Statistics of Glasgow, p. 20.] 

4 [Dublin Journ. of Med. Sci., vol. xii., p. 99.] 

§ [Edinburgh Med. and Surg. Journ., vol* ilvi.j p. 35, and vol* xlvii., p. 329,] 



178 CONTINUED FEVER. 

admissions into the Glasgow Fever Hospital during the year 
1836, were 1116 males and 1141 females,* which is only a small 
excess of females; but if the excess of the female over the male 
population of Glasgow be taken into the account as about one- 
sixth, the proportion of males that have been affected with fever 
will be plus instead of minus. In the same institution were ad- 
mitted, from May 1st to November 1st, 1839, 270 males and 276 
females, classified under typhus. Into the Cork Street Fever 
Hospital, Dublin, from 5th January, 1817, to 30th April, 1818, 
there were admitted 2883 males and 2849 females, which is a 
small excess of males.t Again, in other hospitals, there has 
occurred an excess of females. There were admitted into the 
Waterford Hospital 1277 males and 1452 females, J into the 
London Fever Hospital, 1229 males and 1308 females,§ into the 
Limerick Fever Hospital, 1332 males and 1895 females, being a 
large excess of fernales,|| and into the Edinburgh Royal Infirmary 
962 males and 1075 females. IT From Dr. Mateer's statistics** 
it appears, that of 9588 patients admitted into the Belfast Fever 
Hospital, between May, 1813, and May 1835, inclusive, 5130 
were females, and 4458 were males. Drs. Barker and Cheyne 
remark, that, "in Dublin, when the epidemic had completely 
established itself, the males admitted to hospital were most 
numerous, but in its progress the admissions of females exceeded 
those of males. ... As to the comparative frequency of fever in 
the male and female sex in the country at large, we can form no 
decisive opinion, the answers to our inquiries on that head not 
having been perfectly satisfactory."!! The general excess of the 
female population in large cities will account for this excess.] 

12. The poison of fever is very apt to take effect under the 
casual co-operation of cold, fatigue, excesses, and other occasional 
causes of the febrile inflammations. In many instances fever 
breaks forth apparently from gradual charging of the constitution 
under constant exposure to the morbid emanations, and without 
any other co-operating cause. But in many cases, too, the poison 
seems to lurk in the constitution for a great length of time, unable 
to call forth febrile action ; till at length some decided exposure to 
cold, or some great and fatiguing exertion, especially in the way 
of night-watching, or above all, some unlucky excess of the table 
— any cause, in short, which occasions either unusual exhaustion 
or some decided excitement — suddenly lays the system open to 

* [Cowan's Vital Statistics, p. 19.] 

f [Barker and Cheyne on Fever, vol. i.,p. 91.] 

* [Ibid., p. 193.] 

§ [Dr. S. SmiWs Treatise on Fever, p. 432.] 

|| [Dr. Geary's Report, Dublin Journ. of Med. Science, vol. xii., p. 10.] 

1 [Edinburgh Med.,and Surg. Journal, Oct., 1839, p. 448.] 

** [Dublin Journ. of Med. Scien., vol. x.] 

ff [Barker and Cheyne on Fever, pp. 89-90.] 



CAUSES. 177 

the invasion of the hidden adversary, and fever at once breaks 
forth. Those, therefore, who are much in contact with fever 
patients, can scarcely be too careful in avoiding all sources of 
great depression and exhaustion of the bodily powers. 

13. The ravages of fever are invariably promoted by all cir- 
cumstances of national or public poverty and distress. Seasons 
of scarcity, or of sudden diminution of employment for the work- 
ing-classes, are the sure harbingers of an epidemic visitation of 
continued fever ; and, when these occur during the prevalence of 
an epidemic, its ravages are always very much extended. A 
singular illustration of the latter incident occurred in Glasgow, 
during the late protracted " strike" among the manufacturing 
population for a rise of wages. In 1837 it was ascertained by the 
authorities, that, in consequence of the insane proceedings of the 
workmen, 8000 females alone were thrown out of employment, 
and became utterly destitute for many months. This happened 
during the prevalence of an epidemic, already unexampled in that 
city for extent. Nevertheless, in 1S37 its previous ravages were 
actually doubled ; and about 22,000 of the population were at- 
tacked, of whom a tenth part perished. 

[The connection of epidemic fever with misery and destitution 
is striking. Where we find the poor the least exposed to suffering 
and want, we find them the least subject to fever. "Next to con- 
tagion," says Dr. Grattan, in his account of the fever of Ireland 
in 1818, (p. 11)," I consider a distressed state of the general popu- 
lation of any particular district, the most common and most exten- 
sive source of typhoid fever ; whether this has been the result of 
war, or been produced by the more gradual progress of domestic 
misfortune. . . . The present epidemic is principally to be referred 
to the miserable condition of the poorer classes in this kingdom." 
" That it is always in persons suffering," says Dr. Alison, after 
referring to the sufferings of the Irish in 18 IS, "or who have 
lately suffered, similar privations and sufferings, and the mental 
depression and despondency which naturally attend them, that 
continued fever becomes extensively prevalent, is fully established 
by the history of all considerable epidemics. The elaborate work 
of Drs. Gheyne and Barker, shows that this has been strictly 
true of all the great epidemics which have appeared in Ireland 
since 1700, each of them lasting fully two years, viz., in 1708, 
1720, and 1731, in 1740-41, (after the great frost of 1740,) in 
1800-01, after the rebellion, the transference of the seat of govern- 
ment to London, and the scarcity of 1795 and 1800 ; and again, 
in 1817, after the transition from the state of war to that of 
peace, and the scarcity of 1816 and 1817. That work contains 
reports from the most eminent physicians in all parts of Ireland 
on that great epidemic, all agreeing in the statement, that the 
12 



178 CONTINUED FEVER. 

poor were the greatest sufferers, and the fever seemed to rage 
among them in a degree proportionate to the privations they had 
endured. In Ireland, accordingly, at least during the present 
century, as the general condition of the poor has been decidedly 
worse than either in England or Scotland, so contagious fever has 
never ceased to be more generally prevalent. The same obser- 
vation applies to the epidemic fever in London after the scarcity 
of 1800, (the last great epidemic which has occurred there) — to 
the great continental fever of 1813-14, which followed the track 
of the French army retreating from Russia, but never made much 
progress in the victorious allied army — to the epidemic fever of 
1817, in Italy, consequent on the scarce year 1816 — to the epi- 
demic which affected the British army in Holland, after the dis- 
astrous retreat from Flanders in 1794— in Portugal after that 
from Burgos in 1812— and to that which nearly decimated the 
British legion at Vittoria in 1836." — -(Management of the Poor, 
&c, p. 12.) " That the same cause," continues Dr. Alison, " has 
acted very powerfully in producing the recent epidemics in Scot- 
land, appears distinctly from the following considerations. First, 
it appears from observing the times of these epidemics, the first in 
Edinburgh beginning in 1817, after two bad harvests, and at the 
same time as the Irish one ; the next in 1826, after the great 
failures in 1825, and the sudden cessation, particularly of building 
speculations, in Edinburgh; and the last in 1836, after the great 
depression of trade both in Glasgow and Dundee, with which 
towns the lower orders here are much connected, and under the 
combination of other circumstances already mentioned, which 
have depressed the condition of the poor in Edinburgh of late 
years." Dr. Adams states, that « during the winter of scarcity in 
1799 and 1800, fever from infectious atmosphere was so general 
as to excite us to imitate the example of those manufacturing 
towns which are never free from the disease, and a fever-house 
was established in London."* Dr. Bateman remarks, that "de- 
ficiency of nutriment is the principal source of epidemic fever, 
and that the circumstances just alluded to, (improvement in all the 
arts of life,) operate only as accessories in fostering and multiply- 
ing it will scarcely admit of dispute The last epidemic which 

occurred in London, followed a scarcity of two successive years 
(1799 and 1800) ; and it was during the prevalence of this fever 
that the necessity for establishing a House of Recovery became 

manifest Whether the epidemic of 1817 has been really 

much more extensive than the former, I am unable to determine. 
It might have been expected, indeed, that the present epidemic 
would exceed the last in the extent of its course, since it occurred 
at a period of unparalleled distress among the labouring poor ; 

* {Adams' Inquiry into the Laws of Epidemics, p. 30.] 



CAUSES, 179 

when the loss of employment, occasioned by the termination of 
the war and the general suspension of the manufactures, con- 
curred with the failing harvest of 1816 to increase the difficulties 
of procuring subsistence."* Dr. Tweedie observes that " it is an 
undeniable fact, founded on the experience of many epidemics, 
that there are certain circumstances which render the system 
peculiarly predisposed to the action of febrific causes; and the 
connection of scarcity and privation with the occurrence of fever 
among the lower classes of the community, has been so often 
verified by the experience of epidemics, as now to be received as 
a general axiom."t Dr. Cowan attributes the increase of fevers 
in Glasgow to the same causes. " From the close of 1836, one 
of those periodical depressions in trade, arising from the state of 
our monetary system, has visited this city, and deprived a large 
proportion of the population of the means of subsistence. From 
the existence of secret combinations among the working classes 
in various departments of trade, but especially among the cotton- 
spinners, and the ' strikes' which resulted from these combinations, 
a very large proportion of the inhabitants, in addition to those 
already suffering from the state of the money market, were sud- 
denly deprived of employment, and consequently of the means of 
procuring food. The high price of coal was the means of dimin- 
ishing the hours of labour, and consequently the amount of wages 
in numerous factories, and placed fuel beyond the reach of the 
lower classes for domestic purposes. And in addition to these 
sources of misery, the average prices of grain were much higher 
during 1837 than they had been for some years previously."!] 

14. Fever is probably apt to extend its devastations with pecu- 
liar impetuosity in localities which are damp, or exposed to 
noisome effluvia, arising from organic matter in a state of decay. 
This proposition is generally admitted by authors on fever ; but 
more satisfactory evidence seems desirable, before it can be al- 
lowed to rank unquestioned among the laws of infection. 

[Nothing very positive concerning the influence of weather on 
the propagation of fever, has as yet been ascertained. Whilst 
some writers deny its effects altogether, others who acknowledge 
them, disagree as to their nature. The following table, constructed 
by Dr. Davidson, shows the comparative number of admissions 
in each month, the mean temperature, and average quantity of 
rain. 

* [Batemas- on Contagious Fever, pp. 4-11.] 

f [Tweedte's Clinical Illustrations of Fever, p. 78.]. 

t [Go wan's Vital Statistics of Glasgow, p. 33.] 



280 



COff tlNI/Eff ffEVEK, 









Average 


Months. 


No. of Cases ad- 
mitted • 


Mean 
Temperature. 


quantity of rain 
in inches. 


January . . 
February . « 
March . . , 


2895 
2825 
3152 


36° 

38 
43 9 


1-90 
3-49 
1-39 


April . . . 
May . . . 


3374 

3990 


49 9 
54 


1-84 
2-00 


June . . . 


4365 


58 7 


1-94 


July . . , 


4999 


61 


2-55 


August . . . 


5261 


61 


2-15 


September 
October . . 


5046 
5624 


57 
48 


2-29 
2-41 


November 


5054 


42 


2-79 


December 


5359 


39 


2-58 


51-944 



"This table shows that the greatest number of fever cases were 
admitted into the various hospitals from July to December, or 
during the last six months of the year ; and that during this period 
the average quantity of rain which falls is much greater than 
during the first six months of the year. If we compare any one 
month of the last six with any one month of the first, there will 
be found a similar difference. The same table also shows that 
the temperature may vary considerably during a similar preva- 
lence of fever, and that nearly the same temperature may prevail 
with a great variation in the number of cases. Thus, in August 
the number of cases is 5261, and in December the number of 
cases is 5359, being a difference only of 98 ; but the mean tem- 
perature of the first-mentioned month is 61° ; while that of Decem- 
ber is only 39°; the quantity of rain, however, in both of these 
months is above the average. In March the mean temperature 
is 43° 9, and the number of cases 3152 ; while in November the 
mean temperature is 42°, and the number of cases 5054; but the 
quantity of rain in March is 1°39, while in November it is 2° 79, 
being double the amount of that which falls in the first-mentioned 
month. In February the mean temperature is 38°, and the num- 
ber of cases 2825; while in December the mean temperature is 
39°, and the number of cases 5359 ; but the quantity of rain in 
the first of these months is 1-49 inches, while in December it is 
2-58 inches. 

*-The conclusions which may be drawn from this table, are, that 
in all the months in which the quantity of rain is above the aver- 
age, fever prevails to a greater extent than in those months in 
which it is below this point. It does not appear, however, from 
it that the average range of temperature of this climate has much 



CAUSES. 181 

influence on the prevalence of fever ; for if moisture be present, it 
may prevail to about the same extent, when the average tempera- 
ture is 61°, as in August, or when it is 39°, as in December. The 
diffusion of fever is thus generally connected with humidity of the 
atmosphere. 9 '*] 

It has often been observed, that fever rages to an unusual 
extent, and with peculiar virulence, where the atmosphere is 
constantly loaded with putrid effluvia; and some experiments on 
animals would even seem to show, that an affection like fever 
may be absolutely produced by this cause alone. But many facts 
of a contrary nature are constantly occurring in the history of 
epidemics, which clearly prove that the law is by no means uni- 
versal or even general ; and that it probably applies only in the 
instance of peculiar kinds of effluvia, which, however, have not 
yet been ascertained. 

[Dr. Davidson has so ably condensed all that relates to the 
alleged sources of continued fever from putrid effluvia, that we 
shall transfer his remarks to our pages. " It is a well-established 
fact," he remarks, " that the accidental inoculation of the body 
with decayed or putrid animal matter has produced morbid 
symptoms, resembling in some respects those of typhus fever, and 
many medical men have been so affected, after making necrosco- 
pic inspections. There is always, however, in such cases, exten- 
sive local disease of the member inoculated, or a diffused cellular 
inflammation. According to the researches and experiments of 
MM. Gaspaed, Majendie and Leuret, and Hamont, putrid 
animal matter, when injected into the veins of healthy animals, 
proves speedily fatal,! and putrid vegetable matter acts similarly, 
though to a less degree ; while the symptoms induced have some 
resemblance to those in typhus fever. 

The following were the symptoms which wore produced in a 
dog, into the jugular vein of which M. Gaspard injected a putrid 
solution of fermented cabbage, on the 14th July, 1821. Some 
hours after the injection of the liquid, there were great malaise, 
difficult respiration, vomiting, and great weakness. At the end 
of nine hours a very copious black and liquid stool. On the 15th, 
the weakness was more considerable ; there were lateral decubitus, 
small and feeble pulse, ardent thirst, natural and abundant urine, 
free respiration, strong pulsations of the heart, as in aneurism 
with hypertrophy of that organ. On the 16th, some improve- 
ment, less weakness, no pulsations of the heart, great thirst, dis- 
inclination to food, fever, and occasionally vomiting of drinks. 
17th, the same symptoms. 18th, symptoms aggravated, extreme 
feebleness, staggering locomotion, excessive thirst, red inflamed 
eyes and filled with mucus, tumefied nostrils obstructed with 

* [Davidson, loc. cit., p. 55.] 

f [Chbistxsou on Poi&ons, p, 5S3.J 



182 



CONTINUED FEVER. 



mucus, mucous membrane of mouth red and phlogosed, a liquid 
grayish-white stool with some clots of putrid blood, and death at 
the end of the fifth day of the experiment. On dissection, the 
lungs were found black and slightly inflamed, but still sufficiently 
crepitant. The right ventricle of the heart contained an albumino- 
fibrous concretion, which extended into the superior cava and 
pulmonary artery. The mucous membrane of the intestines, 
especially that of the duodenum and rectum, and a portion of the 
small intestines, was violet-red, as if ecchymosed, inflamed chiefly 
in the form of longitudinal wrinkles and by irregular plaits, which 
variegated the exterior of the intestines before their incision. The 
mucous glands of the rectum were swollen and very distinct. The 
mesenteric glands appeared to be engorged with blood and were 
completely inflamed; the gall-bladder was filled with black, thick, 
and ropy bile.* 

In several particulars the symptoms of a malignant case of 
typhus were exemplified in this experiment upon the dog; the 
small, quick pulse, the peculiar decubitus indicating great weak- 
ness, the black stools, the red colour of the mucous membrane of 
the mouth and fauces, the injected eyes, and finally the staggering 
as indicative of delirium. The necroscopic inspection also fur- 
nishes some points of resemblance, namely, the inflammatory 
patches in the mucous membrane of the intestines, the enlarged 
glands in the rectum, the swollen and engorged mesenteric glands, 
the black, ropy bile ; all of which are pathological appearances 
more or less frequently met with in typhus. M. Majendie found 
that fatal effects were produced by confining dogs over vessels in 
which animal matters were undergoing the process of putrefac- 
tion ; but pigeons, rabbits, and Indian hogs, were not in the least 
injured by a residence in the same cage for nearly a month. He 
repeated many times this experiment with dogs, and always 
obtained the same result with one exception ; but he states that in 
this case the dog was acclimated, for the injection of a putrid 
liquid into his veins had little effect upon him. The symptoms, 
however, are different from those produced by the injection of a 
putrid fluid into the veins ; for the animals seem to die only from 
extenuation at the end of about ten days; and the post-mortem 
appearances are a total absence of fat, of aliments in the stomach, 
and of chyle in the lacteals ; while the mucous membrane of the 
intestines is inflamed, but less so than when putrid matter is in- 
jected into the veins.t It appears, however, well authenticated, 
that workmen employed in peculiar manufactories, and who are 
constantly exposed to the effluvia arising from animal substances 
in a state of putrefaction, are not subject to any of those morbid 

* [Journal de Physiologie, torn. ii. 3 p. 16.] 
f [Ibid., torn, iii., p. 85.] 



CAUSES. 183 

effects which result from the injection of putrid matter into the 
veins, or, according to M. Majendie, to those which result from 
exposure to putrid effluvia ; there must, therefore, be some other 
explanation given of the last-mentioned author's experiments, or 
some unknown concurring circumstances must be required to 
bring the poison into operation. One of the most remarkable 
and repulsive manufactories, or rather nuisances, of this kind is the 
Chantiers d'Ecarrissage de la Ville de Paris. It is an inclosure 
of many acres of ground, situated close to the walls of Paris, and 
has existed for several centuries. Into this receptacle are carried 
the contents of the necessaries of the city ; and the carcasses of 
40,000 or 50,000 horses, dogs and cats are flayed and cut up there 
annually. Various parts of these animals are separated and ma- 
nufactured for sale : the intestines into gut for machinery ; the fat 
is melted for blowpipe lamps ; the flesh, blood, &c, are collected 
for manure; a compost is made to breed maggots for feeding 
poultry, and the bones are chiefly used as fuel. Hordes of rats 
live in this bed of filth, and extend their ravages extensively in 
the neighbourhood. The fetor which arises from it is overpower- 
ing, and often spreads to a great distance. It is remarkable, how- 
ever, and contrary to every preconceived notion that could be 
formed respecting its salubrity, that the workmen of this establish- 
ment and their families are healthy, the most of them being stout 
and long-lived. This fact has been established satisfactorily by 
Parent-Duchatelet. This author states that they have all the 
characteristics of the most blooming health; that in this respect 
they resemble butchers, and that they seem to attain longevity 
more frequently than other artisans. Even new workmen em- 
ployed upon extra occasions, although not acclimated, do not 
appear to be more susceptible, nor do they become affected with 
any disease. During the time that cholera prevailed in France, 
not an ecarrisseur was affected with the disease, and not one was 
sick ; and the mortality of the village, which is in the vicinity of 
Montfaucon, was very small when compared with that of Paris. 
He also quotes the innocuous influence of the human bodies which 
are exhumed to the extent of 200 annually from Pere la Chaise, 
and the exhumations from the cemetery des Innocents, amounting 
to about 20,000 bodies annually, which occupied three years in 
the execution, and which were also carried on during- the greatest 
heats of summer.* Dissecting rooms are also situations where 
putrid effluvia are constantly present ; and it has been affirmed 
that those who are much confined to these places do not enjoy 
good health and are subject to fevers. MM. D'Arcet and Pa- 
rent-Duchatelet state that the most frequent indisposition 
among those who are engaged in dissections is dyspepsia and 

* [Annales d'Hygiene Publique, torn, viii., p, 139.] 



184 CONTINUED FEVER. 

diarrhoea, but that this latter affection is frequent among the 
strangers who arrive at Paris. These authors cite an immense 
number of authorities of the highest respectability, namely Boyer, 
Dttpuytren, Laelemand, Roux, Jadelot, Breschet, &c., to 
prove that dissecting rooms are not insalubrious, and are not pro- 
ductive of fevers. M. Andral states that gastro-enterite, menin- 
gitis and typhoid fever are common among the young eleves of 
medicine during the first year of their residence at Paris ; but so 
little does this depend upon their sojourn in the dissecting amphi- 
theatre, that among those who are affected, there are at least as 
many seized before they commence their dissections as after this 
period. He adds that the health of the men employed in hand- 
ling the debris of dead bodies is similar to that of other individ- 
uals.* The workmen employed in the manufacture of strings 
for musical instruments are exposed constantly to the putrid, efflu- 
via of animal substances, arising from their long maceration, and 
they are not more subject to fevers than other tradesmen. 

Butchers, who are believed by some authors to be almost 
exempt from fevers, are exposed in the slaughter-house to the 
emanations arising from the putrid blood and other animal fluids, 
which are frequently allowed to stagnate, and which are suffi- 
ciently indicated by the fetid and insupportable odour which issues 
from these places during hot weather. The atmosphere of whale 
vessels must be constantly impregnated or rather saturated with 
the effluvium that issues from large and numerous fishes ; yet 
fevers are not prevalent among the seamen. Majendie states 
that the most deleterious animal poison is the putrid water of 
fishes : when some drops of this water are injected into the veins, 
in less than half an hour symptoms very similar to those existing 
in typhus and yellow fever are produced, and the animal dies in 
about twenty-four hours.t It appears from these facts that per- 
sons may live constantly amidst the most concentrated putrid 
animal emanations and yet not contract fever of any type; may 
enjoy health of the most perfect kind j attain longevity in many 
instances, and be less subject to some epidemic diseases than the 
inhabitants in their neighbourhood. It may be asked how are the 
experiments of M. Majendie and others to be explained upon 
this view ? It does not appear from M. Majendie's experi- 
ments that the same symptoms or pathological appearances were 
produced by exposing dogs to putrid animal emanations, as by 
injection of a putrid fluid into the veins ; indeed, he admits this 
himself; but adheres to the belief that the effluvium was the cause 
of death in the dogs subjected to experiment, although no inju- 
rious effects were produced on several other animals. Many ani- 

* [Annates d'Hygiene Publique, torn, v., p. 301.] 
f [Journal de Physiologie, torn, iii., p. 83.] 



CAUSES. 185 

mal poisons, however, operate differently on different organs and 
tissues ; and this is well exemplified in an experiment mentioned 
by Dr. Christison, namely, that " a pupil of Professor Mangili 
swallowed at once the whole poison of four vipers without suffer- 
ing inconvenience ;"* but if a small quantity of this be inserted 
into a wound, poisonous effects are always produced. From a 
consideration of the whole evidence that might be adduced re- 
specting this point, it may be drawn as a conclusion that although 
putrid matters, when injected into the veins of animals, cause 
death under symptoms similar to those of typhus fever, yet that 
the effluvia arising from similar matters do not under ordinary 
circumstances produce any deleterious effects on man. That there 
are exceptions to this general law we doubt not, such as Olivier 
being affected with diarrhoea after visiting a cellar filled with old 
bones, and Chevallier being seized with the same disease after 
exposure to the emanations from dead bodies ; but that the efflu- 
via arising from animal substances in a state of putrefaction con- 
stitute any regular source of continued fevers, we think there are 
no grounds for believing.] 

15. While a distinct account may thus be given of a variety of 
circumstances which regulate the prevalence of fever as an epi- 
demic, occasions also nevertheless occur, when the co-operating 
circumstances are incomprehensible. All the appreciable causes 
which are believed to promote its extension may be wanting, and 
still there is an epidemic which extends instead of diminishing. 
Hence physicians have been reduced to the necessity of inferring 
the existence of hidden atmospheric influences — of some property 
of the air different from any of its known physical properties, or 
perhaps compounded of certain states of those properties — by 
which the propagation of fever is favoured. This co-operating 
cause is universally allowed to exist. Yet, after all, the expres- 
sion denoting that cause is really nothing else than a theoretical 
way of declaring the fact that something exists, with the nature 
of which we are unacquainted. It is a mere cloak of convenience 
for covering ignorance. 

16. Much has been written respecting the propagation of fever 
and other infectious diseases by means of Fomites, or substances 
by which infectious effluvia are absorbed, retained for a length 
of time, and afterwards given off, with the effect of communi- 
cating the disease which produced them. All the investigations, 
however, yet made on this subject are vague. In regard to fever, 
it seems probable that fomites do not contribute much to its pro- 
pagation, and that infection is not retained by them long. 

[Whilst the English army was in Germany in 1743, typhus 
fever prevailed to a great extent among the troops. A number 

* [Christison on Poisons, 3d ed., p. 577.] 



186 



CONTINUED FEVER. 



of tents were given to a workman at Ghent to repair ; he and 
twenty-three of his associates were seized with the fever, and of 
these twenty-four, seventeen died. Sir John Pringle, who relates 
the circumstance, adds, that there had been no direct communica- 
tion between any of the sick soldiers and these persons. Many 
other similar instances are recorded by high authorities.] 

17. [Recency of residence appears to predispose greatly to 
attacks of typhus. To illustrate this Dr. Davidson has constructed 
and published the following table. It comprehends 568 eruptive 
cases, which were admitted into the Glasgow Fever Hospital 
from November 1st, 183S, to November 1st, 1839. It shows the 
number of patients born in Glasgow, the number of strangers, and 
the duration of their residence in Glasgow. 











Males. 


Females. 


Total. 


Natives of Glasgow 


77 


99 


176 


Strangers resident from 1 to 14 days 


12 


4 


16 


2 weeks to 1 month . 


7 


6 


13 


1 to 2 months . 








10 


14 


24 


, 2 to 3 months . 








10 


8 


18 


3 to 4 months . 








5 


5 


10 


4 to 5 months . 








5 


3 


8 


5 to 6 months . 








9 


12 


21 


6 months to 1 year 








29 


26 


55 


1 to 2 years 








24 


17 


41 


2 to 3 years 








13 


10 


23 


3 to 4 years 








6 


11 


17 


4 to 5 years 








12 


4 


16 


5 to 10 years 








29 


32 


61 


10 to 20 years and upwards 




36 


33 


69 




■ 


■ 


— — 




284 


284 


568 



"It appears from this table that among 568 eruptive cases of 
typhus, in whom this point was ascertained, 176 were natives of 
Glasgow, and 392 were strangers: 206 of these strangers had re- 
sided in Glasgow only from one day to two years, and 186 from 
two to twenty years and upwards. The strangers amount to 
about 69 per cent, of the whole number of cases; and those who 
were affected within two years of their residence in Glasgow to 
about 52 per cent, of the whole number of strangers. 

" The following deductions may be drawn from these facts: 1. 
That strangers are more liable to become affected with typhus 
fever than native residents. 2. That the majority of strangers 
are infected within a comparatively short period of their residence 
in Glasgow. 3. That a minor proportion of the strangers, like 
the natives of Glasgow, may escape infection for many years, and 



CAUSES. 



187 



yet be afterwards attacked. These results support the views 
which we have elsewhere given of the laws of typhus. 

" Most of the strangers come from country districts in which it 
may be fairly presumed that typhus does not constantly exist, as 
it does in large towns ; it is therefore probable that the majority 
of them are unprotected by any previous attack ; for if typhus 
attack an individual many times during his life, why should the 
natives of a town containing 263,000 inhabitants, who are con- 
stantly within the sphere of contagion, bear so small a proportion 
to the strangers ?" — {Davidson, loc cit., p. 68.)] 

18. [Typhus fever is a disease of cold or temperate climates. 
Its existence, or diffusion, at least, seems incompatible with a 
tropical sun ; great heat destroying its contagious properties. Dr. 
Bancroft remarks that, "in voyages to the East Indies, ships 
remain for a much longer space of time between the tropics, and 
being also exposed to a higher temperature, the power of heat in 
destroying typhus is in them more decisively manifested, an entire 
cessation of the disease, (however prevalent,) commonly taking 
place before they reach the Cape of Good Hope. It has indeed 
never been known, as I am informed, that a single case of this 
fever has occurred on either side of the Indian Peninsula."*] 

2. Other Causes. — Since continued fever clearly originates 
often in propagation from the sick to the healthy, it becomes a 
second question of much interest, whether it originates in any 
other cause. Authors and practitioners seem in general to be 
very easily satisfied upon this head, and to have decided the 
matter in the affirmative ; nay, some talk with the utmost fami- 
liarity of various special causes, such as cold, fatigue, mental 
emotions, putrid effluvia, excesses of the table, and the like. But 
the question of the origin of continued fever in these causes is 
far from being easily settled to the satisfaction of a philosophical 
mind. 

We know, from the experiments of Majendie, that when the 
lower animals are confined in a narrow space, filled with emana- 
tions from decaying animal matter, they are attacked and killed 
by an affection which bears considerable resemblance to the ty- 
phus of the human race. A few rare cases have been recorded 
of a disease apparently identical with the typhus, having broken out 
in the neighbourhood of places where the dead bodies of animals had 
been accumulated to a great extent, and buried insufficiently deep. 
(Mem. de la Soc. Boy. de Med., i. 97.) In the course of the last 
and previous centuries, it was believed to have been often observed, 
that a disease identical with typhus originated spontaneously in 
the emanations of healthy people accumulated in the loath- 

* [Bancroft on Yellow Fever, p. 500=] 



188 



CONTINUED FEVER. 



some abodes which were then used as prisons throughout Britain. 
The coast-remittent fever of Africa and other tropical countries 
seems to differ little in its characters from synochus with a rapid 
and early stage of typhoid depression. In country districts scat- 
tered instances of a fever occasionally occur, which closely resem- 
ble an indolent synochus, and which the most careful inquiries 
cannot refer to communication with individuals ill of a similar 
disease. In great towns, too, cases of the same nature are met 
with, during the intervals between the epidemics, and in a station 
of life where epidemic fever, in epidemic seasons of the worst 
kind is seldom witnessed. A fever of this description, tedious in 
its course, characterized by much nervous and muscular depres- 
sion, without any particular local disturbance, and especially 
without the marked disorder of the functions of the brain which 
distinguishes most cases of epidemic typhus and synochus, was 
so prevalent among the better ranks in certain streets of Edin- 
burgh some years ago, at a time when fever was not prevalent 
among the working-classes, that a general impression arose among 
professional people of the existence of some unusual local miasma. 
A great variety of parallel facts might be referred to, all leading 
to the general conclusion, that a disease, if not identical with, at 
all events closely resembling, synochus and typhus as described 
above, may arise without the possibility of tracing it to commu- 
nication with the sick. A statement of this kind acquires great 
weight in the instance of such a visitation of disease as that just 
alluded to, which prevailed among people in easy circumstances 
in a great town. We can easily suppose a few scattered cases, 
occurring in a country district or in a city during an interval of 
immunity from epidemic fever, which may have originated in 
exposure to the disease, although the particular exposure cannot 
be traced. But it is scarcely possible to conceive such a disease 
prevailing to a considerable extent among the better ranks, who 
are so remarkably exempt from invasion in the worst epidemic 
periods — more especially too as there is next to a certainty that 
the infection of fever is seldom virulent, and that a very great 
majority of seizures with true infectious fever arise, not from a 
single exposure which might escape observation, but from re- 
peated or long-continued exposure which could scarcely elude 
notice. 

The only condition, then, remaining to enable us to decide in 
the affirmative the general question, whether fever originates in 
any other cause but communication with the sick, is, that the dis- 
ease observed in such circumstances as that just detailed is iden- 
tical with one or other of the three forms of primary continued 
fever of infectious origin. On this point there is room for differ- 
ence of opinion. Many cases of supposed sporadic synocha, 
synochus, or typhus, are clearly cases of gastric or gastro-intesti- 



CAUSES. 189 

rial fever, not recognized or admitted as such by the observer. 
But all cases of the kind cannot be so explained away with can- 
dour ; unless indeed by holding, as some are inclined to do, that 
gastric fever may often occur with the local disturbance so obscure, 
and the constitutional disturbance so predominating, as to render 
the disease wholly undistinguishable from ordinary epidemic 
infectious fever. It is also an undoubted fact, that in cases of 
sporadic fever, occurring either during an epidemic visitation, or 
during an interval, a physician, extensively conversant with the 
features of true infectious fever, is commonly able to pronounce, 
even where the resemblance to the latter disease appears to an 
ordinary eye very strong, that the sporadic disorder is neverthe- 
less not the same with the epidemic forms of the disease. 

The difficulties thus introduced into the present inquiry must 
be admitted to be formidable. At the same time the general 
conclusion to be drawn from the whole facts seems to be that a 
disease, undistinguishable from true infectious fever, may some- 
times arise without infection. Such cases, however, are far less 
frequent than those clearly infectious in their origin. From a 
statistical statement made out by Dr. Welsh in 1819, relative to 
the fever of Edinburgh, it appears, that among 400 cases where 
the patients assigned a distinct cause for their illness, there were 
SO per cent, who were able to refer it to exposure to infection 

(P- 57.) 

On descending from the general question to the more special 
one, what the other cause or causes of fever may be, the diffi- 
culties are greatly increased ; indeed they become insurmount- 
able, with such limited and vague facts as are at present pos- 
sessed on the subject. A long catalogue of causes has been laid 
down in most works on the practice of medicine, or on fever. 
But a variety of circumstances render the inquiries regarding 
them fallacious. Among these, two alone seem sufficient to in- 
troduce interminable confusion and uncertainty. In the first 
place, few inquirers have taken sufficient pains to distinguish 
primary continued fever from irritative gastric fever. And 
secondly, the catalogue of causes alluded to is indebted for its 
length mainly to the non-contagionists, whose testimony may at 
once be rejected altogether in the matter ; for if any individual 
is unable to see in the arguments formerly adduced sufficient evi- 
dence of infection being one cause of fever, how is it possible for 
him to adduce more satisfactory proofs of the operation of any 
other cause ? How is it possible to admit that he is capable of 
weighing evidence dispassionately in any branch of the inquiry ? 
or of proceeding to investigate facts with a calm and unbiased 
disposition ? 

It appears a needless waste of time and labour to attempt any- 
thing farther under this head. Fatigue, mental emotions, atmo- 



190 CONTINUED FEVER. 

spheric exposures, noxious effluvia, and excesses of the table, 
sometimes seem to induce an attack of fever. Often, however, 
the real cause is the lurking poison of infection, which the inci- 
dental source of excitement on the one hand, or of exhaustion 
on the other, calls forth into action. Frequently, too, the disease 
produced in other circumstances is an irritative, not a primary- 
fever. And as for the few instances remaining where true pri- 
mary fever appears to originate in one of the above causes, all 
that need be said farther is, that for one instance where such 
fever follows such cause, a thousand instances occur where no 
effect of the kind ensues; and, consequently, that some more essen- 
tial influence is probably brought into play, than what appears 
merely on the surface of the investigation. 

Whether sporadic cases of true primary fever, originating 
otherwise than in communication with the sick, are capable of 
themselves acquiring the property of self-propagation, is another 
question arising out of the former r which is not less difficult to 
answer. Unless it can be positively determined, that a particular 
case is truly sporadic, there is of course an end to all reasoning 
on the events which follow it. That such cases generally do not 
spread is unquestionable. But from what was said above as to 
the feebleness of infection in ordinary circumstances, this nega- 
tive fact is no argument whatever, though non-contagionists will 
have it so, against the possibility of propagation taking place 
where the conditions are favourable. And in those cases of 
sporadic fever, which there is an opportunity of investigating 
with care, it generally happens that the conditions are quite the 
reverse. The general belief of the profession, and still more of 
unprofessional persons, is, that all primary fevers without excep- 
tion, which put on the type of synochus or typhus are communi- 
cable. Although it may be difficult to show that such is the 
case in regard to true sporadic fevers, the doctrine is sufficiently 
probable. Meanwhile, this is clearly the safer doctrine to es- 
pouse on practical grounds, until the opposite shall be proved; 
because on the one hand it leads to the employment of venti- 
lation and cleanliness, which are useful accessories in the treat- 
ment, and on the other hand it prevents the serious conse- 
quences which would result where infection is mistaken for spo- 
radic fever. If we are to admit that the jail fevers of the last 
and preceding centuries were owing, not to infection, but to the 
vitiation of the atmosphere, where prisoners had been long pent 
up in crowds without sufficient renewal of the air, no doubt 
can be entertained that fevers of spontaneous origin may propa- 
gate themselves. But it is impracticable for any one in the pre- 
sent day to satisfy himself that the real origin of such fevers was 
fully ascertained; and certainly in times somewhat nearer our 
own, when prisons still continued to be too much the abode of 



PROGNOSIS. 191 

filth, foul air, and misery of every description, fever was seldom 
found either to get into them or out of them. 



VII. PROGNOSIS. 

Prognostication in continued fever is founded partly on the 
particular type of the disease, and the general character of the 
reigning epidemic, partly on particular symptoms and groups of 
symptoms, partly on collateral extraneous circumstances. 

From the Type and Epidemic. — Of the three types of con- 
tinued fever synocha is least frequently fatal, typhus most so, 
and synochus intermediate between the two. The general prog- 
nosis will vary accordingly. If it were possible to predict, that 
a case would turn out one of pure inflammatory fever, recovery 
might be confidently predicted, at least in the inflammatory fever 
of this country, and where no signs of severe local inflammation 
are present. Such accuracy of diagnosis and prediction, however, 
is very seldom possible. The more purely inflammatory the 
early stage of synochus is, and the longer its secondary stage is 
postponed, the more favourable does the prognosis become. So, 
too, in typhus, the nearer an approach it makes at the com- 
mencement to synochus, the less likely is it to prove fatal. 

The prognostication founded upon the type in a particular case 
may also be qualified by the habitudes of the prevailing epi- 
demic. Since in some epidemics synocha abounds, in others ty- 
phus, and in others the mixed type, it is plain that, from the com- 
mencement, the probability of recovery must be greatest in the 
first, least in the second, and intermediate in the third. But it is 
not in this obvious and direct way alone that the dominant cha- 
racter of the epidemic influences the mortality, and through it 
the prognosis. For, on the one hand, its remarked, that different 
epidemics of the same type differ in their mortality; and on the 
other, it seems well ascertained, that in epidemics of different 
dominant types, the mortality among cases of the same type 
differs, that is, in epidemics where synocha abounds, intercurrent 
cases of synochus and typhus are observed to be less frequently 
fatal than cases apparently the same in nature, which occur in 
epidemics of pure synochus and typhus. And, on the contrary, 
where typhus is the ruling type, typhus is more deadly, and even 
synochus more frequently fatal, than the same description of 
cases in kind and apparent severity, which are met with where 
the inflammatory character predominates. At all times then it is 
proper in forming a prognosis in a particular case, to regard first 
the particular type, then the frequency of that type in the epi- 
demic, and lastly the general mortality of the epidemic ; and the 
last two circumstances must be regulated by experience on the 
large scale in hospitals. 



192 CONTINUED FEVER. 

From Symptoms. — Prognostics of much importance and con- 
siderable precision may be drawn from particular symptoms, or 
groups of symptoms, or the manner of their commencement and 
progress. 

Where fever commences abruptly with brisk reaction, the pro- 
bability of a regular stage of reaction is greater than where it 
begins slowly and insidiously, and the prognosis, therefore, is in 
general less favourable in the latter case. If reaction, however, 
runs very high, and is not resolved by diaphoretic crisis, but is suc- 
ceeded by a typhoid state, the prognosis is on the whole propor- 
tionally unfavourable, according to the violence of the early reac- 
tion, because the typhoid exhaustion bears some ratio to that 
violence. It is a more unfavourable case where the inflammatory 
state of the circulation gives place to the typhoid stage in the first 
week, than where the transition is postponed till the beginning of 
the second week or later ; and the earlier the change occurs in the 
former instance, the worse is the prognosis. Except in cases of 
synocha, which often terminate altogether before the end of the 
second week, an amendment occurring in special symptoms, or in 
the symptoms generally, towards the middle or termination of the 
second week, is more favourable than where similar changes 
occur in the first week. In the latter circumstance the ameliora- 
tion is often fallacious and temporary ; in the former it commonly 
denotes a crisis. A material temporary amendment on the second 
day of synochus or typhus is not unfrequent, and often misleads 
the patient or his attendant. In like manner, an amendment 
towards evening is a more favourable sign than towards morning. 
In the latter case it may be merely a remission, which is not at all 
uncommon in every type of fever; but in the former, especially 
at or after the middle of the second week, the remission is very 
frequently the commencement of a crisis. If the case passes the 
eleventh day and no decidedly unfavourable symptoms take place, 
nor any general exacerbation, the prognosis becomes more favour- 
able than before ; and so, too, in the same circumstances on the 
fourteenth day. After the seventeenth, however, and still more 
after the twentieth days, matters are reversed, unless some amend- 
ment be observed about those days ; the longer the fever lasts 
after seventeen days, the more unfavourable is the prognosis. 

It is impossible to predict, with any confidence, the probable 
result of a case of fever during the early part of the first week, 
except in so far as a presumption may be formed as to the pro- 
bable type. Special symptoms, and the degree of severity of the 
symptoms, are then extremely fallacious. Cases of synochus, for 
example, but above all, cases of typhus, may be at this time the 
mildest, and yet often become afterwards the worst. Frequent 
rigors, violent headache, irregular distribution of temperature, ex- 
treme prostration of strength, much injection of the conjunctiva?, 



PROGNOSIS. 193 

are among the signs which have been indicated as unfavourable, 
when they occur in the first three or four days particularly. But 
they are unfavourable, not so much in the way of special signs 
of danger, as because they constitute together the characters of 
the type of fever which may be anticipated. It is seldom till 
towards the close of the first, or beginning of the second week, 
that the prognosis from special symptoms acquires some stability. 

The unfavourable signs deserving attention during the latter 
half of the first week are great frequency of the pulse (except in 
synocha), especially in persons towards or after the middle term 
of life, great softness of the pulse, jarring of the pulse at the ex- 
treme of its diastole with easy compressibility, and, above all, a 
weak, fluttering, irregular pulse; a dry, brown, and especially a 
retracted tongue ; irregular temperature of the surface, an erup- 
tion of pale, diffuse petechias, or irregular sweats, with increase 
of fever after them; much headache, especially in typhus, and 
above all, when united with great flushing of the face and injec- 
tion of the sclerotics ; excessive prostration of strength, shown by 
the patient lying on his back constantly and becoming faint on sit- 
ting up; delirium of any kind, but especially either high delirium, 
or muttering delirium amidst a state of stupor, or pleasing deli- 
rium with quickness of expression, and a tendency to smiling or 
risus sardonicus; subsultus of the tendons and tremor of the 
hands; sighing respiration. Several of these symptoms are nn- 
propitious at any time, but they are all peculiarly so if well- 
marked before the close of the first week ; and the earlier they 
appear, the worse is their indication. It is supposed by some that 
no fever patient ever recovers, whose pulse attains 140° in fre- 
quency. This is a complete mistake. In young adults affected 
with synocha the pulse not unfrequently reaches this elevation, 
and even exceeds it, without a fatal event; and occasionally, 
though very rarely, in typhus the same observation is made. Re- 
covery has taken place in the writer's experience where the pulse 
in typhus was 140, and in synocha at 160. 

On the contrary, it may be considered a favourable case of fever, 
which attains the commencement of the second week without the 
pulse being very frequent, or increasing much in frequency about 
that period, without a brown tongue, or irregularity of tempera- 
ture, or petechias, or injection of the sclerotics, or tendency to 
fainting, or subsultus, tremor or delirium. And additional favour- 
able signs are a full, rather soft, and not jarring pulse, which does 
not materially exceed 100 in frequency ; the absence of pungent 
heat ; an eruption of small dark circumscribed petechias ; some 
drowsiness, capable of being easily interrupted ; some desire for 
food, or the ordinary compound drinks, without urgent thirst; 
spontaneous change of position, and occasional lying on the side ; 
deafness, and freedom from intolerance of light. In cases of fever 
13 



194 CONTINUED FEVER. 

assuming, in the first week, the characters of inflammatory fever, 
the most favourable of all special signs is the appearance of gene- 
ral perspiration, between the fourth and ninth days inclusive. 
Before the fourth day sweating is generally partial and without 
effect on the fever; after the ninth it is rare, and seldom benefi- 
cial; but in the interval it is commonly critical. This important 
criterion, however, must be qualified by the habitudes of the pre- 
vailing epidemic; in some epidemics, the appearance of general 
perspiration between the fourth and ninth days of an attack of 
inflammatory fever is the sure forerunner of its speedy and abrupt 
departure. In other fevers, but especially in typhus, sweating 
during this period, instead of being favourable, is often rather the 
reverse : the febrile state does not subside under it, and usually 
increases subsequently. 

The unfavourable signs in the course of the second week of 
fever, are increasing frequency, feebleness, or jarring of the pulse, 
especially a pulse higher than 130 or near 140, which, at least in 
persons towards or above the middle term of life, is, with few 
exceptions, a fatal sign in typhus or the more typhoid forms of 
synochus ; a highly loaded or very dry and retracted state of the 
tongue, with sordes on the teeth and lips; breathing hurried 
beyond proportion to the rapidity of the pulse, and still more 
when interrupted by catches, or intermingled with sighing; a 
marked tendency to coldness of the extremities, coupled especially 
with heat of the head and face ; great flushing of the counte- 
nance, and much dark injection of the sclerotics, especially com- 
bined with very contracted pupils,* or with a half-shut state of 
the eyelids; complete prostration, with a constant supine position, 
and no attempt to alter it; an eruption of either large or crowded 
petechias, of the pale, diffuse, irregularly circumscribed variety ; 
or a jaundiced colour of the skin ; or the appearance of large 
vibices, either on the parts on which the body rests or elsewhere ; 
or redness and excoriation of the skin where subject to pressure; 
subsultus of the tendons at the wrist, trembling of the hands, 
starting of the joints, tremor of the tongue, twitching of the 
muscles of the face, and, above all, convulsions, which last symp- 
tom is, perhaps, invariably fatal ; excessive watchfulness, or, on 
the contrary, profound sopor, from which the patient cannot be 
roused at all, or not without difficulty ; or high delirium, with 

* [Dr. Graves, of Dublin, regards marked contraction of the pupil as one of 
the most alarming symptoms in fever with cerebral disease. " Were I called to 
a case," he says, "in which every other symptom was favourable, but great con- 
traction of the pupil was present, I would say that it was a case of extreme dan- 
ger. A tendency to even moderate contraction of the pupil is a very dangerous 
symptom in typhus; but a pupil extremely or permanently contracted, or, as it 
has been called, a pin-hole pupil, is, or used to be, a fatal sign.'V] 

c [Dublin Journ. of Med. Science, &c. } July, 1838.] 



PROGNOSIS* 195 

Vociferous talking, and tendency to get out of bed, and more 
especially to violence and furiosity ; an anxious expression of 
countenance combined with much stupor; or, on the contrary, a 
pleased expression, with watchfulness, and a hurried, prompt 
manner ; or hippocratic collapse ; involuntary discharge of urine 
and feces ; irregular sweats without abatement of fever. 

The favourable signs during the second week are chiefly nega- 
tive ; that is, the absence of the preceding symptoms, or their 
appearance in a mitigated form. The most important are a 
steady state of the pulse or diminution in its frequency, with in- 
crease of fullness, and disappearance of the jerk at the extreme 
of its diastole ; a moist state of the tongue at the edge, with the 
gradual departure of brownness or foulness, and with increased 
facility of protruding it ; a moderate petechial eruption of the 
small, dark, circumscribed kind; a placid, drowsy expression; 
occasional sleep, with general drowsiness, little or mild delirium, 
and facility of being roused; deafness; sensibility to thirst, and 
some remains of appetite ; a change of posture from the supine 
to the lateral; the supervention of swelling and inflammation of 
the parotid glands; the absence of excoriation from pressure. 
The most favourable of all signs is the departure, towards the 
eleventh or fourteenth day, of any of the more unpropitious prog- 
nostics mentioned above, such as a hurried pulse, dry, retracted 
tongue, vibices, subsultus, tremor, watchfulness, deep sopor, fu- 
rious delirium, involuntary evacuations, and the like : the non- 
extension or diminution of erythema from pressure is also a 
welcome sign; likewise abatement of tympanitic fullness of the 
abdomen : and a sure combination of favourable prognostics is 
extension of moisture of the tongue, subsidence of the pulse, 
supervention of sleep, and return of appetite. One special sign 
is almost always favourable, even where many formidable symp- 
toms are present, namely, deafness; and probably the same may 
be said of a soft, moderately moist condition of the tongue — an 
occasional, though very rare, accompaniment of the advanced 
stage of bad forms of typhus. 

These are the leading prognostications which may be founded 
upon the more essential symptoms of fever. Others may be 
deduced from the symptoms of incidental diseases. Complica- 
tions on the whole render the result more doubtful; but there are 
some, to which unnecessary consequence in this respect has been 
attached, more especially the local inflammations. Local inflam- 
mations occurring early in fever, unless they are violent, which is 
seldom the case, do not in general add materially to the danger, 
because they are for the most part easily subdued; and without 
the necessity of exhausting treatment. It is different, however, 
when they commence in the second week ; for every fresh source 
of irritation or exhaustion is then of importance, and, besides, 



196 pCNTlNUEIr FEVER * 

some local inflammations which commence at that time are obstf- 
nate, and of themselves fraught with danger. 

From Secondary Affections.— The worst accessory affec- 
tions are, great congestion of the brain, if indeed this can be 
properly regarded as a mere accessory disorder — true pneumonia 
— the modification of catarrh proper to the advanced stage of bad 
congestive cases — inflammation of the entero-mesenteric glands, 
or dothinenteritis — peritonitis — icterus with bilious stools— ery- 
sipelas — gangrene and sloughing, especially if they form on seve- 
ral parts. Hence the special indications of the arrival of these 
secondary diseases, as formerly described under the head of the 
symptoms, will often give important warnings of danger, and 
seriously diminish the chance of recovery. Some qualification 
of this statement, however, is requisite, in regard to the symp- 
toms of entero-mesenteric disease ta sloughing. One of the best 
signs of entero-mesenteric inflammation in its early stage, accord- 
ing to all authors who have taken notice of that affection, is 
yellow diarrhoea, commonly associated with tympanitic distension 
of the belly and deep progressive stupor. But repeated expe- 
rience in the epidemics of Edinburgh shows, that even all these 
symptoms may occur without the unfavourable proportions of 
deaths which ought to ensue, were they characteristic of so 
serious a local disease ; and, in particular, that an ochry diarrhoea 
sometimes appears to keep down or even remove the fever, and 
is singly not an unfavourable prognostic. As to sloughing of 
parts subjected to pressure, it is rather remarkable, that, in some 
epidemics at least, this secondary affection is far from being so 
unlucky a prognostic as might he anticipated. In epidemics 
abounding with inflammatory cases, few die who have sloughing 
provided they be properly taken care of; and very seldom do 
they die of the sloughing. If sloughing be confined to the sa- 
crum, and the fever subside at an early period, recovery is rarely 
prevented in any epidemic by this accessory evil. If the fever 
go on unabated, or if the local affection break out on several or 
many parts, the issue is commonly fatal ; and almost always so 
during an epidemic of the typhoid type. 

The favourable prognostics deducible from the secondary disor- 
ders are few in number. On the whole, the cessation of such 
disorders is to be welcomed. Yet the departure of the slighter 
varieties of local inflammation during the first week is of no 
great moment in itself, and has very seldom any influence on the 
result of the primary fever. The removal of violent attacks of 
local inflammation may be regarded as a propitious sign ; but 
the reduction of the strength by the treatment which is rendered 
necessary should not be lost sight of, as a fresh though indirect 
source of danger. 



PROGNOSIS. 197 

From Collateral Circumstances. — There are some collate- 
ral circumstances which exert a very important influence on the 
prognosis in fever ; among which may be chiefly mentioned age, 
sex, constitution, either natural or acquired, and the coincidence 
of cold, fatigue, privation, mental depression, and the like, about 
the period of invasion of the disease. 

Age.— The chance of recovery from fever is greatest in child- 
hood and youth, and diminishes rapidly with advancing age after 
the period of early manhood. Thus, in the Edinburgh epidemic 
of 1818-20, where the mortality was one in 22 for all ages, the 
deaths under twenty were only one in 65; while between twenty 
and thirty they were one in 29 ; between thirty and forty, one in 
IS ; between forty and fifty, one in 11-4; between fifty and sixty, 
one in 6.* Thus, too, in the later Edinburgh epidemic of 
1826-7, where the mortality at all ages was one in 9, that for 
children under fifteen was only one in 41-5; that for youth and 
early manhood, between the ages of fifteen and thirty, was one 
in 13-5 ; that for the middle period of life, between thirty and 
fifty, was one in 5i ; and for people above fifty it was so high as 
one in 2-5. t In like manner in an epidemic in Glasgow, where 
the mortality during twelve months subsequent to October, 1835 5 
was one in 8-* 5 for all ages, that for children under fifteen was 
one in 26 ; between fifteen and thirty, one in 9-5 ; between thirty 
and fifty, one in 4 ; and above fifty also one in 44 An unac- 
countable deviation from this rule has been observed in the 
London Fever Hospital, whence it would appear that the fatality 
of fever in childhood is equal to that for all ages, or very nearly 
so. According to one account, that for 1828-9, when the gene- 
ral mortality of the Fever Hospital was one in 7*22, that for 
children under fifteen was so high as one in 7-33 ; between 
fifteen and thirty, one in 9-5 ; between thirty and fifty, one in 7-33 ; 
and above fifty, one in 2-5. § According to another account, com- 
prising three years subsequent to 1825, when the mortality at 
all ages was one in 6-82, the proportion below the age of fifteen 
was one in 11-33 ; between fifteen and thirty, one in 7 ; between 
thirty and fifty, one in 5-5 ; and above fifty one in 2-25. \\ The 
general rule, however, certainly is, that the chance of recovery is 
greatly superior to the general average, if the patient does not 
surpass the age of fifteen or even twenty; and all accounts agree 
in making the risk to be at least double the general average when 
die age exceeds forty. 

* Welsh, on Blood-letting in Fever, p. 129, 131. 

f Dr. Alison, Edin. Med. Surg. Journ., xxxviii., 249. 

* Dr. Cowan, Vital Statistics of Glasgow, 1838, p. 23. 
4 Dr. Tweedie, on Fever. 

I Px. B, Smith, on Fev&c 



198 CONTINUED FEVER. 

Sex. —Sex has also an important influence. According to the 
tables of Dr. Cowan, for Glasgow, founded on the examination 
of 2259 patients, the deaths for all ages amount to one in 
6-75 among the males, and only one in 11-2 among females. 
The probable cause of this interesting fact is the greater fre- 
quency of habits of intoxication in the male sex. At least 
the difference is scarcely perceptible below puberty, being 
among 550 patients of both sexes one in 25 for boys, and one 
in 28 for girls— a difference which is within the limit of statis- 
tical error, for indeed one additional death among the females 
would reverse the proportion. On the contrary, it becomes very 
marked after the age of 25, when intemperate habits begin to 
produce their effects among working people : for among nearly 
800 of both sexes above that age the mortality among women 
is one in 6-33, and among men, no less than one in 3-1, or fully 
more than double. Conclusions precisely similar may be de- 
duced from the tables furnished by Dr. Welsh, relative to a part of 
the Edinburgh epidemic of 1817-20, where the type was much 
more inflammatory than in the late Glasgow epidemic. In 743 
patients, the deaths for all ages were one in 16 for males, one in 
30 for females ; under twenty years of age the deaths among 
males were one in 68, and among females one in 68 ; and above 
the age of twenty, the mortality among men was one in 11, 
among women, one in 24. 

' Pregnancy. — An extraneous circumstance of great conse- 
quence, and connected with sex, is the fact of a female being 
pregnant at the time. Most pregnant women miscarry during an 
attack of fever ; and, when they do miscarry, a large proportion 
perish. It is impossible to supply numerical data upon this point; 
but the general rule is commonly admitted. The influence of preg- 
nancy on the prognosis, however, seems to differ in different epi- 
demics; and, contrary to what might be anticipated, the influence 
seems to be greatest, judging at least from the epidemics of Edin- 
burgh, in those where the inflammatory type prevails, than where 
typhoid cases predominate. 

Constitution. — It is not easy to calculate numerically the 
effect of constitution on the mortality from fever, as to ascertain 
that of age or sex; but its influence is acknowledged to be great 
— and this both in regard to original and acquired peculiarities. 
The healthy and robust probably suffer less than the feeble and 
sickly. This, however, is by no means easily decided. There 
can be no doubt of the evil influence of recent severe diseases. 
For example, convalescents from acute or severe chronic diseases, 
who take fever in hospitals, have always a violent attack, and a 
large proportion sink under it. There seems little doubt, too, that 



PROGNOSIS. 199 

differences in constitution depending on station in life affect the 
fatality of fever; for it is generally understood, that fever is more 
fatal in the better ranks than among the working-classes of a com- 
munity. There is not any conclusive statistical evidence at pre- 
sent existing for this belief; but the doctrine is conformable 
with vague general observation, as well as with presumptions 
founded on the superior excitability of the brain and nervous sys- 
tem in the upper walks of society. It seems not unlikely, how- 
ever, that an exception should be made in the instance of those 
epidemics of fever, where synocha abounds, and synochus is the 
dominant type; at least it is extraordinary, how few casualties 
have occurred among clinical assistants, and other medical stu- 
dents, during such epidemics in Edinburgh. The most powerful 
modifying influence among constitutional circumstances is, be- 
yond all doubt, that which depends on habits of intemperance. 
In persons of intemperate habits the symptoms of nervous de- 
rangement are always unusually prominent, congestive affections 
are particularly frequent, especially congestion of the brain, and 
all the symptoms are less amenable to treatment than in the con- 
stitutions of the sober and temperate. Hence the mortality among 
drunkards is decidedly far greater than the average. The statis- 
tical account already given of the relative mortality among the 
two sexes after the age at which intemperate habits begin to be 
acquired, is alone a strong presumption of the truth of this fact ; 
for it is not easy to see in what other way the difference which 
actually exists is to be accounted for. But besides, every hospital 
physician knows that the intemperate constitute a very large pro- 
portion of the fatal cases. It would be interesting, and by no 
means difficult to ascertain the proportion numerically ; but facts 
for the purpose do not exist at present. Meanwhile, it is worth 
mentioning, that according to observation of various epidemics in 
Edinburgh, extremely few drunkards who have attained the age 
of forty survive an attack of fever. During the clinical courses 
of five years, prior to November, 1S37, the writer had only one 
case of recovery under such circumstances. 

The coincidence of exposure to cold, fatigue, general privations, 
or mental depression, with the invasion of fever, has commonly 
the effect of rendering the prognosis more unfavourable than it 
might otherwise be. Cold is apt to complicate the fever with local 
inflammations, fatigue to aggravate depression, and disturbing 
mental emotions to increase the nervous derangement and ten- 
dency to congestion of the brain. Of these coincidences the worst 
are mental emotions of the depressing kind. 



200 CONTINUED FEVER. 



VIII. TREATMENT. 

Few diseases are now better understood than continued fever. 
Nevertheless the treatment which has been pursued, and to ap- 
pearance with good effect, is as diversified as may well be ima- 
gined. This physician has trusted to general blood-letting, that to 
local evacuation of blood; one to diaphoretics and sudorincs, 
another to cathartics; some rely on mercury, some on opium, 
many on wine, a few on the cold affusion, and not a few upon 
nature. A cursory survey of these singular discrepancies has led 
sceptics and the whimsical to deny the value of any treatment 
beyond a confident reliance in nature's efforts, together with fresh 
air and the moderate use of laxatives ; nor are there wanting 
practitioners to undervalue the usefulness even of these simple 
adjuncts. It is extremely difficult to settle the real amount of 
benefit derived from treatment in fever, by the only mode which 
can be satisfactory to all, namely, by comparatively statistical 
data. For supposing a sufficiently numerous body of facts were 
accessible for the purpose of comparison, the statistical method of 
inquiry, conclusive as it seems to be, and has been thought by 
many, is really surrounded with as many difficulties and sources 
of fallacy as any other. 

But if the physician, extensively conversant with the treatment 
of various forms of fever, had it in his power to point out to the 
wavering in opinion the immediate and most palpable advantages 
of one method in special cases, and the immediate injury accruing 
from an opposite method, it is not probable that doubts would be 
long entertained by any unbiased understanding ; and a faithful 
inquiry into the causes of the discrepancies in the practice of the 
best authorities in this department of medicine will lead to the 
inference, first, that there may be more than one good method of 
treating the same sort of fever on principles identically the same ; 
and, secondly, that a material difference is rendered necessary in 
the treatment, by differences in the epidemic character of the 
disease. 

In every other branch of inquiry into the subject of fever, it has 
been seen that much deference ought to be paid to its epidemic 
character. In no branch, however, is this precaution more indis- 
pensable than in the treatment. No one can call in question that 
principle, who has been much engaged in the treatment of fever 
for a moderate term of years. Least of all ought any one to en- 
tertain doubts on the subject, who has witnessed the different epi- 
demics which have prevailed in some parts of Britain during the 
last twenty years. The general conclusion at which he must in- 
fallibly arrive is, that the particular type must regulate the treat- 



TREATMENT. 201 

ment in the particular case ; and farther, that the prevalence of a 
particular type must in some measure modify the treatment in all 
types of a particular epidemic. For example, in epidemics where 
synocha abounds, not only are cases often met with whose type 
requires the use of vigorous antiphlogistics, and even of free gene- 
ral depletion ; but likewise in intercurrent cases of synochus and 
typhus, antiphlogistics, and blood-letting among the rest, are bet- 
ter borne and more frequently required, than during epidemics of 
the opposite typhoid character. 

In endeavouring to fix the treatment in a particular case, or for 
a particular epidemic, of fever, it should never be forgotten that 
there are two opposite conditions of the system which must be 
combated, excitement of the circulation and nervous depression ; 
that these states always co-exist more or less ; that their relative 
degree varies from the first in different cases, and prevalently in 
different epidemics ; and that their absolute, but still more their 
relative degree varies much at different stages of the same case. 
It must further be considered, that besides primary nervous de- 
pression, the direct result of the cause of fever operating on the 
nervous system, there is a secondary depression also, the indirect 
consequence of pre-existing reaction. There is no sound founda- 
tion for the opinion of some pathologists, that no other kind of 
nervous exhaustion but the latter occurs in fever. But its exist- 
ence and great importance in many cases cannot be denied ; nor 
yet the influence it must have upon the method of cure. Hence 
it will at once be perceived, that the " indications of cure" in 
fever must commonly be complex and often contradictory. Vio- 
lent reaction should be combated first on its own account, and 
secondly for the secondary exhaustion, which corresponds on the 
whole with its violence. But in combating reaction, care must 
be taken not to do so at the cost of seriously increasing direct 
nervous exhaustion. x\nd on the other hand, while keeping this 
risk in view, it is right to shun providing too much for present 
depression, at the risk of augmenting subsequently that which is 
secondary to reaction. The due consideration of these compli- 
cated circumstances ought to leave no difficulty in understanding 
why so many different and opposite plans of treatment have been 
proposed, and apparently all with no slight success. 

In a practical point of view the most useful and methodical 
arrangement to follow in discussing the numerous remedies em- 
ployed in fever, will be to consider the treatment to be enforced 
at different periods of the disease, adverting at the same time to 
the influence of type on the several measures. Upon this prin- 
ciple five heads may be advantageously adopted, comprising the 
treatment at the commencement, in the early stage, in the middle 
stage, towards the conclusion or final stage, and during conva- 
lescence ; to which may be added a sketch of the prophylaxis. 



202 CONTINUED FEVER. 

At the commencement the object of treatment is, if possible, to 
cut the disease short; in the early stage the principal objects are 
to mitigate reaction, and still also to cut the disease short ; in the 
middle stage to mitigate reaction, and support exhaustion ; in the 
final stage to support exhaustion and maintain life till the fever 
wear itself out ; in convalescence to restore strength and prevent 
relapse ; and at every period a collateral object often arises — the 
removal of secondary local disorders, and of special symptoms. 

Of Incipient Fever. — It has always been a favourite object 
with practitioners, to discover a remedy for arresting fever at its 
outset. The undoubted practicability of suddenly arresting the 
febrile paroxysm of intermittent on its first outbreak, has pro- 
bably led to the inquiry, whether as much may not be accom- 
plished for continued fever also. Some have arrived at a favour- 
able conclusion ; and it has even occasionally been the fashion to 
talk with as great freedom of cutting short typhus and synochus, 
as one would speak of stopping an ague. The general experi- 
ence of the profession, however, is unhappily opposed to such 
views ; and especially the experience of those who are best ac- 
quainted with the true features of continued fever as presented on 
the great scale in hospital practice. It is very doubtful whether 
a true continued fever may be cut short at its outset by any 
means. Even apparent instances of the kind are rare ; and in 
that case, if we consider how impossible it is in the commence- 
ment to distinguish continued fever from ephemera, as well as 
from some local inflammations which may be cut short, strong 
reason will appear for calling the authenticity of the alleged cases 
in question. Good evidence of the power of remedies to arrest 
continued fever at its first invasion is to be attained, so far as can 
be well seen, in one or two ways only, by the arrestment of the 
disease in a fair proportion of cases where it is distinctly threat- 
ened by the usual signs in persons who have been strongly ex- 
posed to infection, and where there is consequently a strong pre- 
sumption that the attack, if not arrested, will really prove one of 
true continued fever in the form of synocha, synochus, or typhus; 
— or by the arrestment of the symptoms of fever in threatened 
relapse in those cases, which, from the general characters of the 
epidemic and of the particular type in each case, are of a kind 
where relapse in the form of true continued fever is probable. 
But on subjecting to this conclusive ordeal the various remedies 
which have been extolled for the purpose, it is apprehended, if 
the writer may judge from his own frequent observation, that 
every remedy for cutting fever short will be found almost, per- 
haps altogether, ineffectual. In the slighter forms of continued 
fever arising in other causes besides infection they may be occa- 
sionally useful: but in the far more numerous and important 



TREATMENT. 203 

class of infectious fevers, febrile action cannot be cut short at its 
origin. 

The special remedy which has been chiefly vaunted for this 
purpose is an emetic of ipecacuanha and tartarized antimony. 
When administered so as to act forcibly during the stage of 
formation of the disease, when chills or rigor are present, and 
febrile reaction not yet fully established, it is held to possess the 
power of arresting the morbid process entirely; and this by 
virtue of the powerful succussion which is given to the whole 
system, followed by diaphoresis and sweating. There is no ques- 
tion that by such practice irregular distribution of temperature 
may be counteracted, and the stage of formation of fever short- 
ened. But it may be greatly doubted, whether any true case of 
infectious fever is ever fairly cut short in that way. 

Emetics, however, are often of much service at the commence- 
ment for another purpose. They remove crudities from the sto- 
mach, which are often present in consequence of the patient having 
indulged his appetite recently before or soon after the invasion of 
the disease. 

Other remedies have been also proposed as useful in the in- 
cipient stage of fever for cutting it short ; and, among the rest, 
general blood-letting. But the efficacy of the whole of them 
is at least as doubtful as that of emetics, so that it would be a 
mere waste of time to discuss their several merits. As for blood- 
letting, it has been chiefly employed with the expectation of cut- 
ting the fever short at a later period, when febrile action is fully 
formed. 

Of the Early Stage. — By the early stage of fever is here 
understood that interval, commonly extending to the first week, 
but rarely later, during which there is more or less reaction of the 
circulation, and the faculties of the mind continue unimpaired. 
In this stage the indications of cure are, to cut the disease short, 
to mitigate the force of reaction, and to remove or diminish special 
symptoms and secondary disorders. 

1. The remedies which have been chiefly trusted to for catting 
fever short in its early stage are emetics, the cold affusion, and 
general blood-letting. 

Emetics are not of more service for this purpose when reaction 
is fully formed, than at the first invasion of fever. They are now 
indeed very generally abandoned as inefficacious when the disease 
has proceeded so far ; and their use is mainly restricted to the re- 
moval of crudities from the stomach. 

The cold affusion was proposed at the commencement of the 
present century by Dr. Currie, as a remedy both for arresting 
and mitigating continued fever. It is applied by seating the pa- 
tient in a tub, and pouring cold water freely from a pitcher over 



204 CONTINUED FEVER. 

the head; and repeating the process as often as the febrile heat 
returns. This treatment is applicable only in cases of synocha, 
synochus, and the few cases of typhus where reaction of the cir- 
culation during the first days is distinct. For a condition much 
insisted on by its discoverer, and found essential by all his imita- 
tors, is, that not only the temperature, as ascertained by the ther- 
mometer, but likewise the sensation of heat, either felt by the 
patient or communicated to the hand of another, shall be steadily 
higher than the natural standard ; and it is only in fevers with a 
distinct early stage of reaction, that the animal heat is so circum- 
stanced. Another condition for the success of the cold affusion 
in cutting short fever is, that it shall be resorted to at an early 
period, especially on the second, or not later than the fourth day. 
At a later period it may be a palliative ; but it is admitted by all 
its admirers to have seldom the effect of arresting the disease. A 
third condition, and one of obvious importance, is that there shall 
not be present any acute local inflammation. 

The success obtained from the cold affusion when practised 
with these precautions seems to have been for some years very 
remarkable; and the confidence of physicians in its efficacy was 
naturally not a little increased by its apparent utility in other 
febrile diseases, such as scarlatina. It is singular, however, how 
short a reputation it has enjoyed. In the first extensive British 
epidemic of continued fever which broke out subsequently to its 
announcement, it was speedily abandoned in a great measure by 
all practitioners ; and for twenty years past it has been almost 
unknown in the treatment. The cause of this fluctuation in me- 
dical opinion is not very clear ; but there can be no question, that 
the change was not made without sufficient reason. The epide- 
mic of 1817-20 — which, it has often been already remarked, 
ravaged more or less the whole of the British Islands — seemed, 
by its eminently inflammatory character, and the high pure re- 
action of its early stage, to be exactly the form of fever for treat- 
ment by the cold affusion. Accordingly the practice was tried by 
many with great perseverance. The general results were, that 
extremely few cases appeared to be checked by it; that, although 
the abatement of febrile heat and restlessness, which was indi- 
cated by Dr. Currie as its immediate effect, occurred almost inva- 
riably, this was, nevertheless, of short duration, and not to be 
made permanent by any frequency of repetition; that, as much 
good eventually was attained by frequent cold or tepid sponging, 
together with cold applied to the head; and that frequently it oc- 
casioned for a short time after each application an intense feeling 
of pressure and weighty pain in the centre of the brain, which 
could not be regarded without some uneasiness. Since that time 
the continued fever of this country has been gradually assuming 
more and more a typhoid type, in which the conditions for sue- 



TREATMENT. 205 

cess laid down by Dr. Currie seldom exist; and consequently 
the treatment has in late epidemics fallen properly into desuetude. 
But its failure in the earlier inflammatory epidemic of 1817-20 
has always appeared unaccountable. Some have even been led 
in consequence to doubt the accuracy of Dr. Currte's observa- 
tions. They were so generally confirmed, however, soon after 
they were published, that such doubts are unreasonable. It can- 
not be rationally denied, that the fever treated by himself and his 
earlier imitators was susceptible of being cut short in its course by 
the cold affusion. And there seems no mode of reconciling the 
discrepancy of the facts relative to the utility of this remedy, ex- 
cept by referring it to those hidden differences in the epidemic 
constitution of fever as well as other diseases, of which, though 
we cannot well indicate their precise nature, we may trace the 
operation in a variety of equally interesting circumstances in their 
history. The time then may come round again, when the cold 
affusion will arrest continued fever ; so that it ought not to be 
forgotten among the remedies to which this property has been 
assigned. 

[Professor Dunglison states, (Prac. of Med., vol. ii., p. 490,) 
that he had many opportunities of witnessing this plan in the 
wards of the Royal Infirmary of Edinburgh, and in none of these 
cases did the disease seem to be arrested ; but the violence of the 
symptoms was occasionally mitigated by it.] 

General blood-letting has long been a favourite remedy in 
continued fever for a variety of purposes. In the present place 
some notice must be taken of its alleged power to cut fever short. 
It was employed to a great extent for many objects in the epide- 
mic of 1817-20; and this is probably the period when its effect 
in abruptly arresting the disease was first fully established. In 
order to employ it efficiently with this view certain conditions 
must be attended to. It is to be used only in cases of synocha, 
or of synochus with a well-marked inflammatory stage. It should 
be resorted to not later than the sixth day, and if possible earlier. 
In the inflammatory fever of hot climates it is probably impossi- 
ble to be too prompt in the use of the lancet after reaction is fairly 
formed. But in the epidemics of inflammatory fever which have 
prevailed in Britain since 1817, it is singular that blood-letting has 
rarely been of any service, if practised before the fourth day with 
a view of cutting short the disease. The remedy must be pushed 
nearly to the same extent as in febrile inflammations. A small 
quantity of blood, whatsoever its immediate effect, is never of ser- 
vice. Faintness ought always to be induced ; but even the secur- 
ing this result will not insure any probability of success, unless at 
the same time the quantity of blood withdrawn be considerable, 
such as twenty, twenty-four, thirty ounces, or upwards. In a 
very few cases so treated the pulse never returns to its state of 



206 CONTINUED FEVER. 

reaction, and the fever is substantially arrested, without the inter- 
vention of any other functional phenomena. In other instances, 
and these more frequent, the faintness is followed by perspiration 
ending in critical sweat ; but more frequently still the febrile ac- 
tion revives, goes on in a mitigated form for a day, and is then 
terminated by a diaphoretic crisis. If not, the repetition of the 
blood-letting may bring on the crisis then, or on the subsequent 
day. Such is a sketch of the effects of general blood-letting in 
the remarkable epidemic of 1817-20, as well as in later epide- 
mics down to 1828. Such particularly were the results where 
the remedy was resorted to on the fourth or fifth day of fever in 
young healthy subjects ; diaphoretic crisis in such circumstances 
might be very confidently relied on before the close of the sixth 
and generally on the fifth day; whereas, in a majority of cases 
of the like kind treated without blood-letting, or left at home with- 
out treatment at all, the disease ran on to its secondary typhoid 
stage. 

In the fevers which have prevailed for some years past these 
salutary effects of general blood-letting have ceased to be pre- 
sented. It has been already repeatedly remarked, that for at 
least fifteen years continued fever has been gradually assuming 
more and more of the typhoid type over the whole country ; but 
especially in Edinburgh has this change been strongly marked. 
A corresponding change has taken place in the effect of remedies, 
and of blood-letting more than any other. Many practitioners, 
trained to its use in previous years, continued for some time to 
adhere to it as the type of the disease changed ; but all have long 
ago ceased to expect that, by such a measure fever may be broken 
abruptly in its progress. 

2. The remedies which have been used for mitigating the 
force of reaction in the early stage of fever are exceedingly 
numerous. They comprehend also a large proportion of the 
best measures for abating or removing special symptoms and 
secondary local disorders. They are chiefly general blood-letting, 
local blood-letting, cold in various shapes, diaphoretics, and sudo- 
rifics, antimonial sedatives, cathartics, and low diet. Other reme- 
dies which have been also employed with the same view, may be 
more correctly considered as specifics, and will be noticed under 
the treatment of the advanced stage, to which they are probably 
more applicable. 

General blood-letting has been much practised in all forms of 
fever since Dr. Armstrong recommended it in congestive typhus, 
and since its general introduction into the treatment of the inflam- 
matory epidemic of 1817-20. Its use in arresting fever has just 
been adverted to. But it has been further practised to a great 
extent for moderating the force of reaction in th® early stage of 



TREATMENT. 207 

all fevers, where reaction is at that period' well-marked ; and it is 
unquestionably a valuable remedy for this purpose, though there 
may be little expectation of cutting the fever short. 

In order to use it with effect and safety the following condi- 
tions should be attended to : — 1. It is most serviceable for mode- 
rating reaction in epidemics which tend to the inflammatory 
character, and in cases which put on the form of synocha or 
synochus. Although some also employ it in the early stage of 
typhus, the prudence of such practice may be greatly doubted ; 
indeed, there is seldom such amount of reaction as to call for 
general blood-letting in a case of genuine typhus ; and the symp- 
toms which may seem to authorize it will for the most part be 
found to yield equally well to the milder remedy, local blood-let- 
ting. General blood-letting has been seldom resorted to, and never 
freely, in true typhoid cases of late epidemics, without reason being 
subsequently seen to regret it when the typhoid stage came to be 
fully formed. 2. It should be employed only where general re- 
action runs high, as ascertained by the state of the pulse, the ani- 
mal temperature, and local signs of inflammation. 3. It should 
be regulated as to extent, partly, of course, by the age and consti- 
tution of the patient, and partly by the type in the particular 
case, but in part also by the prevailing character of the epidemic 
— larger evacuations being borne well in the same description of 
cases in inflammatory than in typhoid epidemics. 4. Of special 
criteria for regulating its extent, the safest and most precise is the 
state of the pulse both before the vein is opened, and likewise 
under the flow of blood. It is most useful where the pulse is 
incompressible, whether it be full or contracted, whether very 
frequent, or moderately so ; and when it improves in softness if 
full, in fullness if contracted — but not under a very slight loss of 
blood. It is least useful and often inadmissible, where the pulse 
is easily compressible, whether soft or jarring, and whatever its 
frequency ; and when, under the flow of blood, it becomes either 
more jarring, or easily and quickly feeble, and fluttering or slow. 
5. The effect on the one hand upon the symptoms of reaction, 
and on the other upon the adynamia or nervous exhaustion, will 
generally decide whether the remedy has been correctly appealed 
to, and whether it ought to be repeated. And where doubts 
may remain as to repeating it, they may often be resolved by 
the state of the blood; which, if presenting a firm clot, and still 
more any appearance of a buffy coat, may warrant the repetition 
of the remedy ; while a clot with little colouring matter, and a 
loose gelatinous consistence, commonly indicates the necessity of 
forbearance. On the whole, much practice and discrimination 
are required to use general blood-letting with advantage and even 
with safety, for moderating reaction in the first week of continued 
fever. If harm originated in the early epidemics of the last 



208 CONTINUED FEVER. 

twenty years, as many with justice have insisted from a dread of 
the lancet, there can be no question, on the other hand, that even 
in these epidemics, and still more in those of recent periods, equal 
injury has accrued from indiscriminate confidence in it, arising, it 
is presumed, from a disbelief in the doctrine, that fever consists 
essentially in part of primary nervous exhaustion, and from an 
overweening reliance in the theory, that this exhaustion is merely 
secondary to pre-existing reaction. 

Local blood-letting is in ail kinds and in all stages of fever a 
remedy of the first importance for a variety of purposes. Among 
other effects it has sometimes that of mitigating reaction in the 
early stage. This is accomplished in one of two ways—either 
"by the quantity of blood withdrawn being such as to have in 
some measure the effects of general depletion, or by its singular 
power in removing local inflammation, even where the actual 
loss of blood is inconsiderable. 

Cold is an approved means of subduing excitement in the 
early stage; and it may be employed advantageously in va- 
rious shapes, such as cooling drinks, cool air and ventilation, 
cold effusion, cold sponging, the cold douche, and other modes of 
applying cold to the head. 

It may seem superfluous to mention cooling drinks in the pre- 
sent day as one of the means of abating reaction and contri- 
buting to the patient's comfort. Yet it is not very many years 
since drink generally was looked on with distrust, and cold drink 
in particular prohibited. In continued fevers of every type, 
however, cold drink is longed for by the patient, and is properly 
allowed, but under two restrictions — first, that it shall be given 
in moderation at each draught to prevent disorder of the stomach 
being induced ; and, secondly, that when diaphoretic crisis seems 
to approach or has commenced, cold shall be exchanged for 
warm drink. Patients in the early stage of fever are extremely 
capricious in their choice of drinks ; and the physician should be 
prepared to indulge them with variety. Barley-water, water- 
gruel and toast- water, the staple drinks of some practitioners, are 
relished by few patients ; currant-jelly water, capillaire-water 
and the like, are also seldom taken long ; lemonade or orange- 
juice-water and effervescing powders are usually more palatable; 
the most pleasant acid drink, however, for fever patients is water 
acidulated with cream of tartar or sulphuric acid ; but that to 
which they adhere longest and throughout every stage is soda- 
water, which, in most circumstances, may be allowed freely. 
When the first week is over, or even earlier, all medicated drinks 
are commonly loathed, and spring-water and soda-water alone 
relished. 

[The abuse of the ordinary drinks administered in fever, is 
apt to produce flatulency, unpleasant distension of stomach and 



TREATMENT. 209 

bowels and increases the tendency to tympanitis. Fluids should 
be given in small quantities and at intervals. A weak infusion 
of cascarilla, or some other bitter, slightly acidulated with muri- 
atic acid, often controls the thirst very effectually.] 

It was at one time the practice to treat fever with warmth and 
close air to keep the fever out. It is long, however, since both 
physicians and patients found that comfort was better secured by 
coolness and ventilation of the air; which, therefore, now hold 
a prominent place among the measures for moderating reaction. 
But many push this article of regimen to excess, thereby occa- 
sioning local inflammations, and even, probably, undue depres- 
sion, especially if they persevere with it also in the advanced 
stage; and accordingly there are some who, from dread of these 
results, seem inclined, even in these modern times, to revert to 
the ancient suffocating system. The truth is, no rule in regard 
to cold air and free ventilation applies in all circumstances. 
Hence the ordinary system of ventilation in hospitals, especially 
in winter, is bad, and all the worse that it is practised only 
during the visits of the medical attendants. The chief rules to 
be attended to are these: — The patient's owmfeelings are gene- 
rally the surest test and may- be safely trusted, so Jong as his 
mind does not wander, even though he demand what his attend- 
ants cannot endure. In inflammatory fever, and the early stage 
of almost all fevers, cool air is of essential service in mitigating 
restlessness and the violence of reaction, and should never be 
withheld except for strong special reasons. The marked bene- 
fit derived from gestation in the open air, which was first urged 
by Dr. Jackson, and has often been experienced in military and 
sometimes in civil practice, is probably in a great measure owing 
to coolness anchventilation. One must have had a severe fever 
to be aware of the luxury of fresh air and a breeze ; and no one 
who has had that advantage will question their general utility. 
The rigour of cool ventilation must be moderated even in the 
early stage of fever, when serious local inflammation is present, 
at least in the larynx, bronchial tubes, pulmonary tissue, perito- 
neum, and intestinal mucous membrane. It must likewise be 
modified where there is irregular distribution of temperature, or 
much nervous exhaustion, and generally in the typhoid forms of 
fever, where the animal heat is little increased. 

The cold affusion has been used for mitigating reaction as 
well as for cutting it short. Its utility for the former purpose 
seems governed by the same rules which govern its application 
to the latter. In fevers, which may be cut short by it near their 
commencement, it allays reaction at a stage too late for that re- 
sult to be expected; in other fevers it is of doubtful service ; and 
the more the disease tends to the typhoid type the more equivo- 
cal becomes the remedy. 
14 



210 CONTINUED FEVER, 

Cold sponging of the whole body, or of the head, face, neck, 
chest, and shoulders, has been substituted with great advantage 
for the more energetic affusion. There are few fevers in which 
reaction is not mitigated for a time in the early stage, and the 
patient's comfort essentially improved, by this remedy, if faith- 
fully persevered in. The heat of the skin, however, ought to be 
above the healthy standard ; irregular distribution of tempera- 
ture must not be present ; and great nervous exhaustion is also 
a contra-indication. In such circumstances tepid sponging is pro- 
perly substituted. There is no use in medicating the water with 
vinegar and the like, except to inspire the attendants with more 
trust in the remedy, and thus secure its faithful application. 

The cold douche of the head, wet evaporating cloths, and the 
ice-bag, are often of great service in moderating reaction ; but 
their influence is probably indirect, through means of their ope- 
ration as local remedies in moderating determination towards the 
head. 

More reliance, perhaps, has been placed in antimonial seda- 
tives for allaying reaction in the early stage of continued fever 
than in any other remedy. Antimonials have been used in three 
ways in this stage — according to the contra-stimulant plan in fre- 
quent large doses, in small doses as nauseating sedatives, and in 
still less doses as diaphoretics. The contra-stimulant method, the 
theory and details of which are explained in other parts of this 
work, and which, if not first conceived, was at all events first suc- 
cessfully propagated as a doctrinal practice, by Rasori, consists 
in the administration of doses of tartar emetic every two hours, 
varying from one to two or five grains or upwards ; and it is 
represented that the effect is simply to reduce reaction, to act as a 
constitutional counter-stimulant, without necessarily any other 
physiological action being developed among the various actions of 
the kind possessed by this antimonial preparation. By this method 
Rasori maintained that very many febrile diseases, and continued 
fever among the rest, may be successfully treated. Without pre* 
suming to decide the general question of the efficacy of such prac- 
tice in continued fevers at large, it may be simply mentioned, that 
no success whatever has attended the trials made of it in the late 
fevers of Britain, and that the contra-stimulant phenomena even 
have not been witnessed at all. And as a proof of the fairness 
with which these trials have been conducted, it is right to add, 
that in the hands of those who made them, the same practice was 
found to elicit in pneumonia and some other organic inflamma- 
tions all the essential phenomena which Rasori describes. The 
method by nauseating doses of James's powder and tartar eme- 
tic, is a much more ancient and general practice than the Rasorian 
plan. It was much confided in by Cullen, and continues still 
a favourite system of cure both among his disciples and others. 



TREATMENT. 211 

It appears well established, that doses of about a quarter of grain 
of tartar emetic given every one, two, or three hours in one or 
two ounces of some convenient liquid vehicle, so as to keep up 
nausea, with as little vomiting as possible, will often contribute in 
some fevers to keep down reaction in their early stage. But in 
many epidemics the effect of this kind is slight and equivocal. 
Especially has this been the case for some years past in the Brit- 
ish continued fever : so that, although still generally pursued by 
many, the practice seems rather to rest on routine prejudice, than 
on satisfactory evidence of its utility. It appears on the whole 
most serviceable in the early stage of those forms of synochus 
which approach to typhus, and may be in them advantageously 
substituted for general blood-letting. The result is never in any 
case at all to be compared with the effects of the same practice 
in the advanced stage of some febrile inflammations, such as 
pneumonia, or in the early stage of erysipelas. As to the third 
method of administering antimonials, namely, as diaphoretics, all 
that can be said on this head may be equally well stated under 
the head of diaphoretics in general. 

In 1817, when the rising medical generation first saw continued 
fever on the large scale, they found almost every case treated as 
a matter of course with diaphoretics. The pharmacopoeia of 
every hospital teemed with diaphoretic formulae, in which acetate 
of ammonia and tartar emetic performed a conspicuous part, and 
of which every fever patient had his share. It was universally 
observed, however, that the diaphoretic plan, whether by antimo- 
nials or otherwise, was of no avail ; diaphoretic mixtures were 
banished, except from routine practice ; and this method has 
never regained any footing since. The truth seems to be, that in 
some forms of sporadic fever of a mild kind, especially those oc- 
curring in children, which are not referable to infection, and which 
approach in nature to irritative gastric fever, diaphoretics are 
often singularly serviceable, but particularly the solution of acetate 
of ammonia in two-drachm or half ounce doses frequently re- 
peated, or frequent doses of an eighth of a grain of tartar emetic 
largely diluted, or James's powder, to the extent of three, five, or 
seven grains occasionally. But when fever assumes the epidemic 
form in cases referable to infection, this practice is wholly futile. 
We are bound to receive with deference the favourable statements 
of the physicians of the last century on this matter. But the truth 
cannot be denied, that their great antiphlogistic weapon, the dia- 
phoretic method of cure, has proved pointless in all recent British 
epidemics. Sudorifics have been less extolled at all times in 
fever; and it is apprehended that few now think of employing 
them in the well-marked and severe forms of epidemic fever, 
where, if they were useful at all, there would not be long want- 
ing satisfactory evidence of their efficacy. 



212 CONTINUED FEVEE. 

The employment of cathartics for checking early reaction in 
fever first became general about the beginning of the present cen- 
tury, through the writings of the late Dr. Hamilton of Edin- 
burgh. Like other enthusiasts, Dr. Hamilton pushed too far his 
confidence in his favourite method ; and some of his imitators 
brought it into discredit by trusting to it alone where more powerful 
and instant means were necessary, or by resorting to it in circum- 
stances of great exhaustion, where neither the discharge occasioned 
by free purging, nor the consequent fatigue, could be borne with 
impunity. In all cases of continued fever in the early stage, un- 
less where some peculiar contra-indication occurs, mild laxatives, 
such as moderate doses of senna, castor-oil, rhubarb and mag- 
nesia, aloetics, and the like, are essential in modern British prac- 
tice for counteracting the tendency to constipation, which is very 
regularly present at this period. More active doses of senna, the 
compound colocynth mass, neutral salts, fortified or not by tartar 
emetic, are also prevalently resorted to at first for occasioning 
brisk purging ; because such a measure is clearly found service- 
able in keeping down febrile reaction. Perhaps no combination 
in general answers better for the purpose than either the com- 
pound colocynth mass at night, followed by sulphate of magnesia 
or some other neutral salt in the morning, or a solution of an 
ounce and a half of sulphate of magnesia, and two grains of 
tartar emetic in twelve ounces of water, of which two, three, or 
four ounces are given every hour, or alternate hour, according to 
the effect produced or desired. The refrigerant sedative action of 
such treatment is often unequivocal. In cases of typhus of the 
pure kind, especially where the adynamia is great and early, the 
purgative method must be mitigated and confined to simple 
evacuation of the contents of the bowels. The exhaustion is 
otherwise dangerously increased ; and even hazardous fits of 
fainting are induced by the frequent exertions which are ren- 
dered necessary. In cases, too, where inflammation of the in- 
testinal mucous glands is formed or threatened, it is commonly 
held by those conversant with the particular form of fever, that 
all purgatives except the gentlest are inadmissible. But others, 
admitting their questionable service in such circumstances, also 
with some show of reason add, that the local disease of the 
bowels is in all probability apt to be developed in consequence 
of the physician neglecting the bowels while in a state of pro- 
tracted constipation. 

Low diet is an indispensable part of the treatment in the early 
stage for subduing general reaction. But the physician is seldom 
put to much trouble in prescribing this measure, since nature 
generally enjoins it by removing the appetite ; and the principal 
duty of the medical attendant is confined to controlling the in- 
discretion of friends, who will often be scarcely persuaded that 



TREATMENT. 213 

a patient in fever may live with little or no food for days and 
weeks together. The simplest farinaceous articles, and even 
these in small quantity, with tea and such other slightly nutritive 
liquids, constitute the brief diet-roll of the fever patient in the 
early stage of his illness. 

3. The last of the indications of cure in the early stage of, 
fever is to abate and remove local disorders and special symp- 
toms. The most important remedies which come under this 
head are those employed for arresting local inflammation ; which 
will therefore be mentioned in the first instance. 

Secondary local inflammations may be often arrested by the 
same means which are rendered advisable for subduing general 
reaction. Hence they are often removed when reaction in the 
early stage is mitigated; and more frequently they disappear, 
although the reaction, the more direct object of the treatment, 
should, as often happens, continue unabated. Local inflamma- 
tion in fever is for the most part much more easily subdued than 
either the fever itself or idiopathic inflammation. It is seldom, 
for example, that general blood-letting is required for this alone. 
Local evacuation of blood is commonly sufficient; and where 
there seems a necessity for opening a vein, the loss of blood re- 
quired is comparatively inconsiderable. Hence in the laryngitis, 
catarrh, pneumonia, and other local inflammations of fever, the 
employment of a few leeches may generally prove an active 
enough remedy, so far as evacuation of blood is concerned ; and 
this observation applies peculiarly to those epidemics which tend 
to the typhoid type. Blisters are also often of effectual service, 
especially in catarrh, pneumonia, and gastric irritation, where 
they frequently act with energy although local depletion has 
failed. Rubefacients even are sometimes of service, especially in 
cynanche tonsillaris and the slighter form of laryngitis, which in 
these climates is a common accompaniment of fever. Tartar 
emetic in nauseating or diaphoretic doses is useful for combating 
local inflammation, particularly catarrh and pneumonia, although 
of little moment as a general antiphlogistic against the fever itself. 
In cynanche tonsillaris some advantage is derived from the cus- 
tomary stimulant gargles; in laryngitis, from mucilaginous de- 
mulcents and inhalation of warm water and vinegar ; in bron- 
chitis, from expectorants, more especially squill united in the form 
of a mixture of the syrup with laudanum or muriate or acetate 
of morphia; in cynanche parotideea, from warm fomentations 
and poultices. In entero-mesenteric inflammation, which seldom 
however commences, or at least betrays its presence, in the early 
stage of fever, the most promising treatment consists in the ap- 
plication of leeches repeatedly to the abdomen, particularly in 
the right iliac region, the faithful employment of fomentation, the 
administration of large doses of chalk mixture with half-drachm 



214 CONTINUED FEVER. 

doses of ipecacuan wine and a little laudanum, the use of gently 
anodyne clysters, where the diarrhoea is very troublesome, and 
perhaps gentle mercurialization of the system, with occasional 
gentle laxatives where other remedies induce too constipated a 
state of the bowels, or, instead of laxatives, gently stimulant 
clysters. 

Of other local affections the most material are determination 
of blood towards the head, and gastric irritation. Headache, a 
symptom seldom entirely wanting, and always when present 
much complained of, is most effectually relieved by leeches and 
cold evaporating cloths. In fevers of a typhoid tendency the 
former remedy is the more effectual of the two. It is indeed 
surprising to observe, how often a few leeches in the early stage 
of typhus, or typhoid synochus, will remove or materially miti- 
gate headache for the rest of the fever. When, on the other 
hand, the tendency of the fever is to the inflammatory type, cold 
evaporating cloths are usually more serviceable, particularly when 
preceded by leeches : but, to do any good, they must be applied 
much more carefully than is customary, especially in hospitals. 
In severe cases, a bladder half filled with broken ice may be 
advantageously substituted for wet cloths; but it must be ob- 
served that few patients can bear for more than a few minutes at 
a time the pungent impression thus made upon the integuments, 
and that the ice should be frequently removed for a short inter- 
val. The ice-bladder is particularly serviceable where headache 
is combined with much heat of the integuments of the head, and 
generally in all cases where the symptoms appear to threaten 
secondary local inflammation. Cold ablution of the head is pre- 
ferred by some patients, and is also an excellent remedy. [Dr. 
Graves is of opinion that warm applications are applied much 
less frequently than they ought to be for the relief of headache 
and cerebral symptoms. Warm vinegar and water, he says, will 
generally be found to be the most efficacious application in the 
ordinary headache of fever.] Convulsions with coma, occurring 
in the early stage of fever, were stated in a former section to be 
invariably fatal. Copious blood-letting from the arm, as well as 
the temporal artery, the ice-bag to the head, powerful cathartics, 
the warm bath, and on the other hand also stimulants, have been 
tried in the cases observed in Edinburgh, but without making any 
impression on the disorder. 

Gastric irritation in fever may amount to inflammation, and is 
often treated successfully as such by leeches and blisters to the 
epigastrium, occasionally united with gentle anodynes. But the 
same remedies are also frequently very useful, where no doubt 
can exist that the nature of the affection is irritation at most, or 
nervous and functional. Tenderness at the pit of the stomach, 
a common symptom, is most effectually subdued by leeches, par- 



TREATMENT. 215 

ticularly in typhoid cases. Sickness and vomiting are sometimes 
relieved by frequent small quantities of cold drink, sometimes by 
effervescing draughts, more generally by leeches, but best of all 
by a blister over the stomach. 

In the hepatic affection, described among the secondary ab- 
dominal diseases as an occasional accompaniment of fever in the 
early stage, and as characterized by a jaundice colour of the skin, 
and, commonly, bilious stools, the most efficient treatment is 
prompt mercurialization. Such cases have generally been ob- 
served in the epidemics of Edinburgh to resist all other remedies, 
and to prove swiftly fatal, with extreme prostration. But in 
several instances, where calomel was given in a large quantity, 
to the amount, for example, of a drachm in twenty-four hours, 
recovery took place ; and the crisis was coincident with the first 
appearance of mercurial action. 

Such are the leading points to be attended to in the treatment 
of continued fever in its early stage. This stage, it has been 
often observed, commonly lasts for one week. When the fever 
continues longer, the nervous exhaustion begins to predominate, 
reaction declines, typhoid symptoms are soon developed, and 
new indications arise in the treatment. These may sometimes 
originate, however, long before the close of the first week, occa- 
sionally even near its commencement. The necessity, therefore, 
of a very different plan of treatment from any yet mentioned, 
being required, in some instances, at a very early period of fever, 
must never be lost sight of. But in a very great majority of 
cases, no such necessity arises till the close of the first, or begin- 
ning of the second week ; and it is observed that, on an average, 
those cases do best where antiphlogistic or "expectant" treatment 
may be continued till then. 

Treatment of the middle stage. — The middle stage of fever, 
as characterized by time, may be said to extend from the close of 
the first week to between the eleventh and seventeenth days. 
But, more correctly, it comprehends the interval between the 
period when the symptoms of nervous exhaustion begin to pre- 
dominate, and the period when a favourable crisis is promised, 
or a fatal event is threatened. In this stage, the objects of treat- 
ment are to mitigate reaction, to support exhaustion, and to sub- 
due local disorders. 

1. In many cases and epidemics of fever, which present a 
marked typhoid character, the force of reaction in the middle 
stage is so inconsiderable, that it may be almost disregarded in 
the treatment. But in other cases, and in particular epidemics, 
reaction continues an important object in the method of cure, and 
not the less so, that it is complicated with some degree of nerv- 
ous exhaustion or typhoid depression. Accordingly, it happens 
sometimes that, for this purpose, the active antiphlogistic mea- 



216 CONTINUED FEVER. 

sures of the early stage may be requisite even in the course of 
the second week. Far more generally, however, the practitioner 
must bear in mind that exhaustion of the strength, the indirect 
result of previous excitement — as well as the development of the 
primary nervous depression, which is never wanting in one de- 
gree or another in any case of fever — renders it indispensable to 
mitigate materially the energy of the antiphlogistic method. 

More especially do these remarks apply to the use of general 
blood-letting. The employment of it may be governed by the 
same rules as for applying it to the treatment of reaction of the 
circulation in the early stage. But the contra-indication, arising 
from the risk of injuriously augmenting exhaustion, is doubly 
strong in the middle stage. Much practice is required to use it 
judiciously at this period. The general rules are, to observe 
carefully the prevailing character of the epidemic, the particular 
type of the case, and the condition of the pulse. And, in judg- 
ing from the state of the pulse, care must be taken not to err, as 
the inexperienced are apt to do, by mistaking for a firm pulse of 
reaction the full, jarring, but easily extinguished pulse, which is 
common in the middle stage of fevers of the typhoid or ady- 
namic type. On the whole, the prevailing impression seems to 
be, that general blood-letting is, for the most part, a questionable 
remedy for abating reaction in this stage ; that more injury than 
good has been done by its introduction into practice with that 
view, in consequence of its having been used too indiscrimi- 
nately by the inexperienced or the prejudiced ; and that a better 
indication for its employment is the removal of congestion of in- 
ternal organs. 

Of other antiphlogistics, cool air, cold drinks, and cold or 
tepid sponging, are much in use for moderating reaction in the 
middle stage. Their extent and degree must be regulated by 
nearly the same conditions as in the early stage, and always 
mitigated where exhaustion is great, or the temperature of the 
body either irregularly distributed, or not elevated. Antimonial 
sedatives are of no use ; and the whole class of diaphoretics are 
equally inefficacious. Such, at least, is the experience of practi- 
tioners in the epidemics of the last twenty years. Cathartics are 
of more general application than other antiphlogistics. A mode- 
rately open state of the bowels, by means of any of the purga- 
tives formerly mentioned, seems to answer better in the gene- 
rality of cases of primary continued fever in this country, than 
any other means of counteracting general excitement in the 
middle stage. But, for reasons formerly given, they must not be 
used too freely; and all drastics must be shunned, where the 
primary nervous exhaustion, or secondary depression, is very 
great. And, likewise, they are contra-indicated by entero-mesen- 



TREATMENT. 217 

teric disease. Where debility forbids the use of purgatives, it is 
essential to maintain the bowels open by means of clysters. 

2. The counteracting of exhaustion is, in a majority of cases 
of fever, the most important object of treatment during the mid- 
dle stage. In not a few cases, as already observed, it even be- 
comes an essential part of the system of cure in the early stage. 
Pathologists have indicated two varieties of nervous exhaustion 
as occurring in the middle stage of fever, one primary and essen- 
tial, produced directly by the cause which excites the fever, the 
other secondary, the consequence of antecedent reaction, and 
observing some ratio to the degree of that reaction. Although 
this is probably a correct distinction in a pathological point of view, 
it is of no great moment, so far as regards the remedies for the 
state of exhaustion ; for in either case it may be similarly treated. 

The chief remedies for exhaustion are wine and other alcoholic 
fluids; to which some add camphor, opium, chlorine, yeast, cer- 
tain saline mixtures, and mercurialization. The food also at this 
period sometimes requires regulation. Some of these remedies, 
indeed, may be regarded more correctly as administered in the 
shape of specifics, than as mere stimulants for counteracting ex- 
haustion. But they may nevertheless be considered, without 
great impropriety, under the present head. 

When the state of exhaustion is well marked, it is seldom pos- 
sible to do without wine or some other alcoholic fluid. Wine is 
commonly preferred, and in this country the stronger wines are 
thought most suitable. But when the adynamic state is very 
great, the stimulus of wine is sometimes insufficient, and it be- 
comes necessary either to add strong spirit to the wine, or to sub- 
stitute diluted spirits. This step is often peculiarly necessary in 
the instances of habitually intemperate livers, in whom wine, in 
such quantity as may be conveniently administered, has little or 
no effect, simply because their constitutions have become proof by 
habit against the influence of weak potations. Malt liquors can 
seldom be used instead of wine or spirit, because they are not 
strong enough for ordinary purposes, and because they are apt 
to disorder the stomach by means of their extractive ingredients. 
The quantity of wine or spirit which is necessary, varies exceed- 
ingly. No definite rule can be laid down on that point. Gene- 
rally it is right to limit the first administration to four ounces, or 
two wineglassfuls of wine in twenty-four hours. Many patients, 
however, eventually use a whole bottle without injury, though 
previously unaccustomed to any alcoholic fluids ; and even this 
amount is not unfrequently exceeded. A person not habituated 
even to wine, has been known to take for a short time two bottles 
of port and half a bottle of brandy, without any other than a 
salutary effect on the pulse and general course of the disease ; but 
this is an extreme case. The wine may be given alone, or made 



218 CONTINUED FEVER. 

into drink with cold or warm water: and an excellent mode of 
administering it, where the patient is not too torpid, is with a little 
soda-water. 

The best indications for wine are a soft and not jerking pulse, 
a tongue without much yellow or white coating, a temperature 
not particularly elevated, paleness, or at least diminished flushing 
of the face, the absence of local inflammation, and a drowsy tor- 
por, without either high delirium, or, on the other hand, profound 
coma. The opposite signs are not always contra-indications; but, 
when any of them are present, wine is not so certain a remedy ; 
and some of them imply preliminary or cotemporaneous treat- 
ment of another kind. A small wiry, or full hard pulse is com- 
monly a positive contra-indicant. So, too, are a very foul loaded 
tongue, considerable elevation of temperature, smart local inflam- 
mation, much flushing of the face, with heat of the head, pulsa- 
tion of the temporal arteries, and other symptoms of cerebral 
determination of blood. High delirium and deep coma are 
not always contra-indicants, as they may arise from excess of 
depression ; but they are sometimes associated with obvious de- 
termination towards the head, or congestion of the brain ; and in 
that case stimulants should be avoided for a time, or more fre- 
quently treatment by general stimulants should be combined with 
local treatment by leeches, cold, and blisters, as will presently be 
described under the head of remedies for the secondary disorders 
of the middle stage. 

The proper time and occasion for commencing the use of wine 
often involve a very nice practical question. On the whole, more 
harm is done by resorting to it too soon, than by withholding it 
too long ; and it is right, if possible, to get the patient through the 
first week before administering it ; which is generally practicable, 
except in marked typhoid cases. As in many circumstances some 
doubt will exist whether the time for it may have arrived, great 
consequence is always attached to close observation of the effects 
of the first few doses. If the pulse become more frequent, or 
more jarring, or the tongue more dry, or the flushing of the face 
worse, or the breathing quicker, or the stupor deeper, or the deli- 
rium or restlessness greater, it must be abandoned. If the pulse 
expand, or soften, or lose its jarring character, or fall in frequency; 
if the tongue becomes softer, moist on the edge, and more easily 
protruded ; or the countenance continue clear, with the eye more 
lively, or the breathing softer and less noisy, or the stupor more 
easily interrupted and more similar to mere sleepiness, or the de- 
lirium and restlessness less considerable — the remedy has been 
appealed to at the proper conjuncture, and may be continued. 

[Dr. Stokes has proposed to deduce from the cardiac pheno- 
mena, a rule to regulate the administration of wine and other 
stimulants in continued fever. His proposition is : that in the 



TREATMENT. 219 

diminished impulse, and in the feebleness or extinction of the 
first sound of the heart, toe have a new direct and important 
indication for the use of wine in typhus fever. In typhus, ac- 
cording to Dr. Stokes, there are two conditions of the heart dia- 
metrically opposite. In the one, the impulse is either altogether 
wanting, or very feeble, with a diminished intensity of the sounds. 
In the other, the heart's action continues vigorous throughout the 
progress of the malady. The state of the skin is not an index 
of these two cardiac conditions; the surface frequently giving 
the sensation of intense heat, whilst the heart's action is feeble. 
And, on the other hand, the converse holds good ; an alarming 
rapidity in the cardiac action, with every appearance of utter 
prostration, the patient being cold, pulseless and livid. The con- 
dition of the circulating organ must be determined by the appli- 
cation of the hand and the stethoscope, to the infra-mammary 
and sternal regions. Dr. Stokes supports his views by a number 
of illustrative and confirmatory cases. Dr. S. regards the action 
of wine upon the heart in typhus, as both sedative and stimulant: 
sedative in diminishing its frequency ; stimulant, in restoring its 
impulse and muscular sounds. In other cases, the existence of 
the cardiac phenomena at an early period of the disease, led him 
to anticipate the bad symptoms, and to commence in good time 
the use of the great remedy ; and in others, notwithstanding the 
presence of severe visceral irritations, the use of stimulants was 
adopted with the best success, from the same indication. The 
experience of Dr. Pennock, of this city, supports that of Dr. S.* 
Dr. Stokes expresses his solemn conviction that it is to the fear 
of wine in typhus, as well as to an ignorance of the principles 
which should guide its exhibition, that the immense mortality in 
this affection is to be mainly attributed; he adds, that in no pre- 
vious epidemic had he given so much as in the one he is treating 
of, and in none was he ever so successful. In one case the 
amount of stimulants employed was enormous ; and although of 
a most unpromising character, it terminated happily. The patient 
was an elderly woman, admitted in a state of great prostration, 
three weeks after the invasion of the disorder. Wine, 292 oz. ; 
Brandy, 20 oz. ; Porter, 7 bottles ; Ethereal enemata, 2 bottles ; 
besides jelly, beef-tea, &c. Dr. Graves considers that suffusion 
of the eyes should not contra-indicate the use of wine, as it may 
result from want of sleep; nor a hot skin, particularly where there 
is, at the same time, a tendency to coldness of the extremities.] 

It sometimes happens, that, where wine has thus been properly 
administered, although it acts for a time beneficially, yet in 
twenty-four hours or upwards it begins to act injuriously, pro- 
ducing the contra-indicating phenomena just mentioned. This 

* [Med. Examiner, vol vii., p. 123, 1843,] 



220 CONTINUED FEVER. 

is a circumstance not always adverted to by those extravagantly 
addicted to prescribing wine in fever. But it certainly does ap- 
pear as if sometimes nature were the better for a little temporary 
impulse in the shape of wine, and nevertheless cannot stand con- 
tinued stimulation. Observations of this kind occur particularly 
in synochus, and, above all, where the preliminary stage of reac- 
tion is distinct. On the contrary, it is a far more general rule, that 
where wine has been clearly proved by its first effects to be a 
proper remedy, the artificial stimulus, once obtained, must be 
regularly kept up by stated doses, which must be also occasion- 
ally increased. Attention to this rule is especially necessary in 
the night-time and towards morning, when the state of depression 
is at the lowest. The fidelity of the personal attendants of the 
sick during this period should be scrupulously insured if possible. 
It is well known to hospital physicians, that not a few severe cases 
of fever in the typhoid state are lost in consequence of being 
neglected in the night-time, and left for some hours without the 
stimulus which they had been accustomed to receive during the 
day. 

Little need be said of the other remedies mentioned above, as 
occasionally employed to counteract typhoid exhaustion. Opium 
has been used by a few in frequent small doses as a stimulant ; 
but its fitness for this purpose is generally distrusted, and the 
danger arising in the latter stage of typhus and synochus from 
congestion, especially of the brain, seems a sufficient contra-indi- 
cation. 

[The employment of opium in fevers is a point of great nicety, 
requiring extreme caution and discrimination. The indications 
for its use have been accurately stated by Drs. Latham and 
Stokes. " When the disorder of the sensorium outruns the other 
symptoms ; when by venesection or topical bleeding, or by alvine 
evacuations and refrigerants, the general and local symptoms are 
relieved, but the delirium still continues; when to this state are 
added tremors, subsultus tendinum, and unrestrained evacuations; 
when there has been, at first, high vascular excitement, and large 
evacuations have been required to guard the brain or other organs 
from mischief, and wild delirium has followed; if the patient has 
previously been in a delicate or nervous state ; if he has been 
addicted to an excessive use of spirituous or vinous liquors, par- 
ticularly the former ; if the habits of the patient and his occupa- 
tions have been such as to inordinately excite and exhaust the 
sensorium; or if the anxieties, the toils, or the debaucheries of life 
have previously injured the health, and more especially the state 
of nervous energy ; in these several circumstances should opiates 
be resorted to in the advanced progress of typhoid fevers, and of 
synochoid fever that has passed into the nervous or typhoid 



TREATMENT. 221 

state. 5 '* Dr. Stokes considers that these circumstances demand the 
use of opium in fever. 1 st. Where there is persistent watchfulness. 
2d. Where an inflammatory condition of the brain has existed 
and been subdued, but delirium or other nervous symptoms still 
remain. 3d. Where an excited state of the sensorium exists 
without heat of scalp, or remarkable throbbing of the arteries of 
the head. Dr. Watson says that it is in that form of fever, called 
by the French ataccique, where the patient is affected with de- 
lirium, restlessness, wakefulness and spasm, and the disturbance 
of the nervous system outruns that of the vascular — a condition 
closely resembling that of delirium tremens — that opium is so bene- 
ficial. Where the symptoms are well-marked, a tolerably full dose 
of opium, or one of its preparations, may be given in the even- 
ing. " But/ 5 as Dr. Latham remarks, « there are cases where the 
indications for the employment of opium are doubtful. Wild 
delirium and long wakefulness, and a circulation weak and flut- 
tering, seem to call for a considerable dose of opium. Yet withal 
there is a certain jerk in the pulse, so that we cannot help sus- 
pecting that the blood-vessels have something to do with the 
sensorial excitement. Under these circumstances I have certainly 
seen twenty minims of laudanum produce tranquil sleep, from 
which the patient has awoke quite a new man. But I have also 
seen the same quantity produce a fatal coma, from which he has 
never been roused. Now since it is a fearful thing to strike a 
heavy blow in the dark, where the alternative is of such magni- 
tude, it is the safest and best method to administer a small dose, 
at intervals of an hour or two, so as to stop short of actual mis- 
chief at the first glimpse of its approach, or to be led, by a plain 
earnest of benefit, to push the remedy to its full and consummate 
effect. Many doses may be required for this purpose; but we 
shall see, after the first or second, whether to go on or to desist." 
Dr. Pereira says, " Yet I have seen opium fail to relieve the 
delirium of fever, even when given apparently under favourable 
circumstances; and I have known opium to restore the conscious- 
ness of a delirious patient, and yet the case has terminated fatally. 
If the skin be damp, and the tongue moist, it rarely, I think, 
proves injurious. The absence, however, of these favourable 
conditions by no means precludes the employment of opium; but 
its efficacy is more doubtful." (El. Mat. Med., Am. ed., vol. 
ii., p. 704.) Dr. Henry Holland suggests that the condition of 
the pupil may serve as a guide in some doubtful cases — where it 
is contracted opium being contra-indicated. {Med. Notes and Re- 
flections, p. 427, 2d ed.) Dr. Graves has extolled, in extrava- 
gant terms, a combination of tartar emetic and opium in continued 
fever with prominent cerebral symptoms. 

* [Latham, in Lond. Med. Gaz., vol. x., p. 11.] 



222 CONTINUED FEVER. 

R.— Ant. et potas. tart. gr. iv 
Tincturse opii f^i. 
Aquae camphorse f^viiij. 
M. 
Sig. — - Half a tablespoonful to a tablespoonful every two hours. 

This treatment Dr. G. claims as "peculiarly his own." Dr. 
Law, of Dublin, recommended it through the columns of the 
London Medical Gazette previously to any publication on the 
subject by Dr. Graves.*] 

Camphor was highly thought of by Cullen, and is still admi- 
nistered by many, partly as a sedative of the nervous system to 
allay inordinate irritability, partly as a stimulant of the circula- 
tion to counteract debility. It is given in the form of emulsion, 
and in the dose of one or two grains every four or six hours. 
Cullen, however, urges that the smallness of these doses was 
the reason why many practitioners complained of not obtaining 
the good effects he announced ; and that five grains ought to be 
administered at a time. Now-a-days few put any trust in this 
remedy in a genuine and severe case of continued fever. 

[Dr. Gerhard derived great benefit from the use of camphor 
in the Philadelphia epidemic of 1836, where the nervous symp- 
toms were prominent. "Camphor," he says, "was certainly 
amongst the most useful and powerful of our remedies. We 
used it largely in the severe cases, especially those in which the 
ataxic nervous symptoms were very marked; and we had no 
reason to repent its employment. In general there was a marked 
diminution of some of the most prominent and harassing symp- 
toms. We gave the camphor in emulsion in doses of five grains, 
every two hours, and in enema in doses of a scruple. The im- 
mediate effect was the lessening of the subsultus and tremors, for 
which it was chiefly administered, and sometimes the diminution 
of delirium. In some cases we possessed a complete control over 
the subsultus, which was immediately checked by an injection 
containing a scruple of camphor. It would cease for some hours, 
but afterwards return nearly with its former severity. Still it was 
a useful palliative, and, like most remedies of its class, acted as a 
useful balance-wheel in preserving the harmony of the system 
until the disease had passed through its natural course. The 
camphor frequently acted powerfully as an anodyne when sleep 
had been interrupted by the previous disturbance of the nervous 
system." Huxham is high in his praise of camphor. " Its ano- 
dyne demulcent quality," he says, "makes it vastly serviceable, 
in quieting the erethism, and bringing on composure of spirits 
and easy sleep, when opiates fail, nay augment the tumult and 
hurry."] 

* [Lond. Med. Gaz., vol. xviii., pp t 538-694.] 



TREATMENT. 223 

In recent times, among other new remedies for fever, yeast, in 
frequent doses, has been proposed as a means of opposing exhaus- 
tion ; but it has not come into so general use, that any opinion can 
be formed of its utility. [This remedy has been used extensively 
by Dr. Stoker, who,' after an experience of thirty years with it, 
speaks highly of it, in all the stages of typhus. It is not only seldom 
rejected by the stomach, when any other medicine can be retained, 
but the patient, in such cases, often expresses a liking for it. Yeast 
has been objected to on the ground of its being likely to increase 
tympanitic distension. Dr. Stoker, however, states, that in some 
of the most obstinate cases of tympanitis, enemata of yeast and 
assafoetida have proved the most efficacious remedies. According 
to this authority yeast is laxative, and supersedes, in a measure, 
repeated doses of purgative medicine. He ascribes its efficacy to 
the power of correcting the morbid contents of the alimentary 
canal, and consequently the symptoms of putrescence, and asserts 
that, in his idea, petechias and black loaded tongue will be found 
more effectually remedied by it than any other medicine. Dr. 
Tweedie says, " from our personal experience of yeast, we cer- 
tainly think it a remedy deserving attention in the low forms of 
fever." (Cyc. Pratf. Med., Am. ed., vol. ii., p. 196.) It may 
be administered alone, or with any medicine which it may be 
advisable to join with it. Two tablespoonfuls may be given in 
water, or with an equal quantity of camphor mixture, every three 
hours. Should it purge too much, a few drops of laudanum may 
be added to each dose. If the stomach is irritable it may be 
given in the form of enema, four ounces being mixed with an 
equal quantity of gruel.] 

The same may be said of chlorine in the shape of chlorine- 
water: at first employed as an antiseptic in the days when 
putrescency of the fluids was a received dogma in the pathology 
of fever, it has been more recently recommended as a stimulant, 
or a specific against the typhoid state. But no satisfactory evi- 
dence has hitherto been adduced in its favour. 

[Dr. Copland, whose experience on this point has been con- 
siderable, says, " the chlorinated soda is a valuable medicine 
in all the typhoid forms of fever, when judiciously prescribedo 
It may be given early in the putro-adynamic variety, when ex- 
citement is imperfect or low, and the skin discoloured, or petechias 
are appearing, and continue throughout the disease. But when 
vascular reaction is considerable, or local determination promi- 
nent, particularly in the nervous and exanthematic varieties, this 
substance should be withheld until these states are subdued, or 
about to lapse into the nervous stage. At first, it ought to be 
prescribed in small doses, so as not to offend the stomach : in 
from ten to fifteen drops of the solution, as prepared by Labar- 
raque, every three or four hours in camphor julep, or in an 



224 CONTINUED FEYER. 

aromatic water. As the disease passes into a state of exhaustion 
or of manifest putro-adynamia, or when there are a lurid skin, 
low, muttering delirium, stupor, meteorismus, black sordes on 
the tongue, teeth, &c, the supine posture, unconscious, offensive 
evacuations, petechia?, blotches, a disposition to gangrene in parts 
pressed upon, coma, &c, it should be given in larger doses, or 
more frequently, and in tonic infusions or decoctions, or with 
camphor, serpentaria, or other stimulants and tonics. I have 
seen it productive of great benefit in such cases, but it should be 
commenced before these symptoms appear, and be persisted in, 
as its good effects are seldom manifest in less than three or four 
days, or more ; and it should not supplant the use of wine, 
opium, suitable nourishment, and other means which the stage 
of the disease and peculiarities of the case may suggest. It 
should also be frequently administered in enemata ; and the sur- 
face of the body ought to be often sponged with a stronger solu- 
tion of it in warm water, with the addition of camphor. M. 
Chomel has lately given the chlorinated soda an extensive trial ; 
and he states that it has proved more successful in low fevers 
than any other means, when persevering] y employed. Dr. 
Graves has also recently employed it, and has found it ex- 
tremely serviceable. It acts, first, on the tissues with which it is 
brought in contact as a gentle stimulant and antiseptic, and is 
most probably partially decomposed in the digestive organs, and 
reduced to the state of common salt. In this state it is carried 
into the circulation, where it supplies the waste of this substance 
that has taken place in the early stage of the disease."] 

Much interest was excited a few years ago in this country by 
the saline treatment of fever, a novel mode, originating in the 
doctrines of Dr. Stevens, relative to the dependence of fever on 
alterations in the blood. Conceiving that fever arises in loss of 
the saline ingredients of the blood, he naturally proposed to make 
good that loss by administration of the proper salts ; and accord- 
ingly to trust the cure of the disease mainly to frequent doses of 
muriate and carbonate of soda, united with a little of the chlorate 
of potash. This treatment Dr. Stevens represented to be so suc- 
cessful in the remittent and yellow fevers of Trinidad, that upon 
one occasion 340 cures were accomplished in a military corps 
without a single death ; and again, during an interval of nearly 
two years, 1010 cases were treated with a mortality of only one 
in ninety-two. It remains for Dr. Stevens' brethren in the 
West Indies to say, whether these statements are conclusive or 
fallacious — which has not yet been done. Meanwhile, the notion 
that such treatment will apply to the typhoid fevers of temperate 
countries is erroneous. In the trials made of the saline method 
in Edinburgh, no advantage whatever could be observed in well- 
marked cases. The treatment, moreover, is based on what ap- 



TREATMENT. 225 

pears a grave pathological error ; for the reduction of the saline 
materials of the blood in fever does not exceed the reduction of 
the colouring matter, the changes of which in respiration the 
salts are intended to secure, and the alterations of the blood, so 
far as they have been hitherto determined, are consecutive, not 
primary — the effect, not the cause of fever. 

[When Dr. Stevens commenced the saline treatment, he pre- 
scribed a strong solution of the muriate of soda with nitrate of 
potash, except in cases where there was acidity of the stomach. 
He now recommends a combination of twenty grains of the chlo- 
ride of sodium, thirty grains of the carbonate of soda, and eight 
grains of the chlorate of potash. He administers this powder, 
dissolved in water, every two or three hours, according to circum- 
stances, during the middle and last stages of fevers. According 
to Dr. Stevens, these salts enter directly the circulation, and do 
not irritate the stomach and bowels'; and if given before the 
stomach has ceased to perform its functions, the bad symptoms 
soon disappear. A solution of the chloride of sodium (two table- 
spoonfuls to a pint and a half of tepid water, or thin gruel) may 
also be occasionally thrown into the bowels. The strength is at 
the same time to be supported by strong beef tea. In extreme 
cases Dr. Stevens thinks life may occasionally be saved by in- 
jecting a saline solution into the veins. 

The chlorate of potash was recommended by Garnett and 
other writers, and more recently by Dr. Hunt, of Manchester. 
Dr. Copland has prescribed it since 1819, and considers it as a 
valuable medicine, especially in the advanced stages of typhoid 
fever. When excitement, or vascular reaction, is about to pass 
into the nervous stage, and when inflammatory determination 
has been removed, the same authority adds, this salt will be pre- 
scribed with benefit. Dr. Watson states that he has long em- 
ployed it with advantage ; and under its use he has remarked, 
in many instances, a speedy improvement of the tongue, which, 
from being furred, or brown and dry, has become cleaner, and 
moist. It may be conjoined with tonics and camphor, or it may 
be given in doses of five or seven grains, every two or three 
hours, in tonic infusions, or in larger quantities at longer inter- 
vals; a drachm may be dissolved in a pint of water, and a pint, 
or pint and a half of this solution given daily.] 

The mercurial method of treating continued fever has at vari- 
ous times had its advocates, but it has never come into general 
use. Its followers maintain that the antiphlogistic properties of 
mercury render it peculiarly applicable to the removal of fever; 
that, the development of mercurial action being incompatible with 
another action going on at the same time in the system, fever 
must cease where mercurial erethism is excited ; and in particu- 
lar that, by its influence in rousing the energy of the capillary 
15 



226 CONTINUED FEVER. 

vessels, it has a salutary effect upon their state of congestion in 
the latter stage. Many, however, deny that these theoretical 
views are realized in practice ; and, on the whole, the prepara- 
tions of mercury, as mercurials, are little used in the present day. 
From the trials made in late Edinburgh epidemics, it would ap- 
pear that the induction of mercurial erethism has sometimes a 
good effect in the instances of congestive typhus where the head 
is peculiarly affected ; that in such cases, however, mercurial 
action is not easily excited ; that in other varieties of fever it is 
less serviceable ; and that where its immediate advantage seems 
undoubted, much suffering and injury to the constitution may be 
occasioned by its ulterior effects. 

The regulation of the food, in the middle stage of fever, is 
sometimes to be conducted upon different principles from those 
simple rules which have been seen to direct this branch of the 
treatment in the early stage. For the most part, indeed, the pa- 
tient refuses aliment of every sort, even in the middle stage ; and 
where a little food is taken, his tastes confine him to simple fari- 
naceous articles — the only alimentary substances which at this 
time the stomach can generally endure. Towards the close of 
this period, however, especially in cases of typhus or synochus of 
a severe description, where there are great languor and exhaustion 
of the bodily powers, the patient will sometimes surprise his im- 
mediate attendants by suddenly demanding animal food. It has 
been found that, wherever such request is not dictated by mere 
incoherent rambling, it may be safely acceded to, and is, even in 
circumstances otherwise most unfavourable, a very propitious 
sign. In all cases, and in all stages of fever indeed, except in 
convalescence, the dictates of nature in respect of food may in 
general be followed without risk of injury. 

[A cardinal point in the treatment of typhous fever is attention 
to the diet of the patient — to prevent, indeed, his dying of starva- 
tion. It is a well-known fact that protracted abstinence from food 
will induce a train of symptoms analogous to those observed in 
the worst forms of typhus. A rigorous abstinence observed during 
the course of so protracted a disease as typhous fever, is a mean 
by which much harm has been done. After the third or fourth 
day of the disease, nourishment should be given, and perse veringly 
continued in during the course of the disorder. Gruel, panado, 
— the farinaceous articles generally — should be allowed in small 
quantities, frequently during the day, at first. Broths, jellies, &c., 
become necessary at a later period.] 

3. The removal of local secondary disorders in the middle stage 
of fever is very generally an important object of the treatment ; 
and it is often rendered peculiarly so by the concurrence of great 
typhoid exhaustion, which is in some measure incompatible with 



TREATMENT. 227 

the vigorous employment of local remedies. The local disorders 
of the middle stage are mostly the same with those of the earlier 
period. The treatment, too, is upon the whole similar, but modi- 
fied merely in degree by the more exhausted state of the nervous 
system and general bodily powers. 

Local inflammations are best treated by moderate topical eva- 
cuations of blood, chiefly with leeches, and by such speedy coun- 
ter-irritants as mustard cataplasms or blisters. It is surprising 
how much the ordinary local inflammations of the continued 
fever of this country are under the control of moderate topical 
depletion in the middle stage of the disease. So much is this the 
case, that the theoretical question, whether general blood-letting 
is admissible for the same purpose in that stage, is one which sel- 
dom occurs in actual practice. Blisters are peculiarly serviceable 
in inflammatory affections of the throat and chest. 

Of all local disorders in the middle stage, those which are of 
most consequence in the fevers of Britain, are clearly affections 
of the head; because they are the immediate cause of a very 
great proportion of the mortality from fever. These affections, it 
was formerly seen, sometimes present the inflammatory character, 
but much more frequently the characters of cerebral congestion 
merely. Where the symptoms are such as are commonly 
thought to indicate an inflammatory tendency, that is, where the 
face is flushed, the head hot, the temporal stronger than the ra- 
dial pulse, the delirium active and noisy, and the patient restless, 
unable to sleep, or inclined to roam about, the most appropriate 
treatment consists of leeches occasionally to the temples, evapo- 
rating cloths, the ice-bag, and the cold douche of the head, to- 
gether with occasional cathartics. No remedy equals the cold 
douche, in such circumstances, for subduing restlessness and 
active delirium. Where, on the other hand, cerebral congestion 
is the nature of the local disease, as indicated by a feeble though 
often jarring pulse, great prostration and stupor tending to coma, 
a dingy complexion, dark injection of the conjunctivae, subsultus 
of the tendons at the wrist, and the like, little advantage is 
derived from cold applications, which are so useful in more 
active affections. But local depletion by leeches is often ser- 
viceable ; and more frequently marked benefit is obtained from 
blisters applied over the whole head. With these remedies 
ought to be united occasional laxatives where the bowels are 
constipated, or still better, perhaps, purgative clysters, especially 
if the debility be very great; also warm fomentations of the 
limbs, mustard cataplasms to the calves, or other means of excit- 
ing gentle counter-irritation of the extremities. With the local 
treatment it is generally necessary to unite the use of wine, for 
maintaining the strength and counteracting typhoid exhaustion. 
This general measure is by no means incompatible with the use 



Z&O CONTINUED FEVER. 

of local evacuants and counter-irritants, as might appear on a 
hasty view of their respective actions. In point of fact,-marked 
and speedy advantage is often obtained in the worst forms of 
cerebral congestion by the combination of wine for its general, 
with blistering of the head for its local, effects. Blisters ought 
not, in such circumstances, to be applied to the nape of the neck, 
as is the practice of many, unless where no other space is left ; 
lor, at the very least, great torture is occasioned to the patient 
during the weak, irritable condition of convalescence, and fre- 
quently vesication is followed by exhausting suppuration, some- 
times by dangerous sloughing. The practice of others of apply- 
ing blisters between the shoulders, in such circumstances, is still 
more to be avoided. Superficial suppuration is then almost ine- 
vitable, and fatal sloughing not uncommon. 

Secondary affections of the chest, when inflammatory in na- 
ture and not of prior existence to the fever, are in general easily 
removed in the middle stage by local depletion, sinapisms, or 
blisters. The affection of the bronchial membrane, which was 
described formerly among secondary disorders, under the title of 
congestive catarrh, is best treated by blisters united with the 
proper general treatment of the typhoid exhaustion, in which 
state alone it is ever observed to become considerable. 

Of local disorders of the abdomen the most material is entero- 
mesenteric inflammation, which generally first shows itself in 
this stage. Its treatment has been already described under the 
treatment of secondary diseases in the early stage. 

Among diseases of the skin, the most frequent requiring at- 
tention is excoriation from pressure, tending to gangrene and 
sloughing ; and one of the most dangerous, though fortunately 
not of common occurrence, is erysipelas. In the middle stage of 
fever, especially towards the close of the second week, the sa- 
crum is so apt to become erythematous from pressure, that it 
ought always to be examined at this period twice a day. At 
first it may be mitigated for some days by altering the pres- 
sure with pillows, and by frequent anointing the parts, either 
with a liniment of equal parts of white of egg and rectified 
spirit agitated together, or with a lotion of equal parts of opium 
and acetate of lead in one hundred parts of water; and many 
sore backs may in this way be saved, by simply delaying the pro- 
gress of the erythema for a day or two, till the crisis which is 
approaching shall be formed. But these remedies are only palli- 
ative if the fever continue long ; and sloughing in that case almost 
invariably follows. When gangrene has formed, the best re- 
medy is the turpentine liniment, covered with a poultice. Erysi- 
pelas may sometimes be successfully treated by small nauseating 
doses of tartar emetic, especially if administered early in the 
attack. Other remedies for this disease in its idopathic form are 



TREATMENT. 229 

seldom of service ; and indeed it is on the whole an intractable 
disease in fever. Phlegmasia dolens is best treated by free local 
evacuation of blood, and warm fomentations ; and if suppuration 
take place, by graduated pressure. 

A few special symptoms in the middle stage require attention. 
Sleeplessness is often grievously complained of by those patients 
who do not fall into a state of torpor, or into the opposite condi- 
tion of riotous delirium. Sometimes their complaint is ima- 
ginary; but where real, advantage is often found in meeting it 
by the administration of opiates. Opiates are chiefly useful in 
two states — when there is sleeplessness without delirium or ten- 
dency to stupor, and when there is restless delirium in concur- 
rence with a soft pulse, and the general signs of exhaustion. In 
either case the criterions which are favourable to their employ- 
ment are a pulse compressible and not jarring, no great flushing 
of the face, freedom of the conjunctivas from particular injec- 
tion of vessels, and a soft tongue, neither much loaded, nor very 
dry and brown. In most circumstances where opiates are ser- 
viceable they disagree if too often repeated. The best signs of 
their administration having been judicious are quiet sleep with 
refreshment on awaking, and a moister state of the tongue. If 
they produce more delirium, or no refreshment, notwithstanding 
that sleep was their immediate effect, or if the tongue become 
more dry and brown, they should be abandoned. 

A symptom not uncommon in the middle stage, especially in 
cases occurring among young adults of the better ranks, is an ex- 
cessive disposition to leave the bed and roam about. This tend- 
ency should never be controlled by too violent measures. If it 
cannot be prevented by gentle resistance, it is often effectually put 
an end to by occasional indulgence. The straight Avaistcoat, which 
many heedlessly resort to, should be reserved for those cases only 
where the tendency is accompanied by violence or furiosity, and 
must be combined with the cold douche of the head. The patient 
ought never to be left alone, when there is this tendency to quit 
his bed. Syncope may be induced by efforts to accomplish what 
is beyond his strength ; or fatal accidents may arise from his 
reaching an open window or a stair-case. So many attempts, 
some of them unhappily successful, have been made of late by 
young people in fever in Edinburgh to leap their windows, that 
this form of delirium is probably either communicated by ex- 
ample, or suggested by the precautions seen to be taken against 
the danger. 

A very inconvenient and common symptom in the middle stage 
of typhoid fever is tympanitic distension of the abdomen. In 
severe cases, it is scarcely possible to remove it until a crisis take 
place, and then it promptly disappears without any remedies. The 
most useful treatment consists in the occasional administration of 



230 CONTINUED PETER. 

stimulant and carminative clysters. Purgatives by the mouth 
often increase it, unless where the bowels have been neglected in 
a state of Constipation. Another very inconvenient symptom is 
distension of the hypogastrium from retained urine. This affec- 
tion is so common in the middle and final stages of bad cases of 
typhus, that the practitioner should always make inquiries into 
the state of the urinary secretion, or daily examine the region of 
the bladder. It may be removed sometimes by stimulant clysters ; 
but the catheter often becomes necessary. 

Op the Final Stage. — By the final stage is here understood 
the short period, commonly of two or three days at farthest, which 
usually precedes a fatal event or a favourable crisis, and also that 
which constitutes the period of crisis. A distinct head has been 
made of this interval ; because when it has fairly arrived, the 
time for every sort of treatment is generally past, except what 
consists in supporting the patient against primary and secondary 
exhaustion. There is good sense in the quaint indication laid 
down for the treatment in the final stage of fever by authors at 
the close of the last century — namely, to counteract the tendency 
to death. When the disease has reached thus far, it seldom con- 
tinues long; it has a natural limit in the generality of cases ; and 
if the patient can be kept alive for a few days — for example, be- 
yond the seventeenth day, he will for the most part recover, where 
no serious secondary disorder threatens life. During this import- 
ant period little is called for in a great proportion of cases, except 
the faithful administration of the stimulants which have previously 
been found of- service ; and when an improvement occurs, it is 
commonly right to abandon opium, if it had been previously given 
as a calmative and hypnotic ; to countermand counter-irritants or 
local evacuants ; to be on the watch for the period when general 
stimulants should be reduced; and to offer small quantities of 
simple articles of food. Laxatives should also be given sparingly, 
and clysters commonly administered in preference. Much atten- 
tion must be paid to erythematous parts^ and those which were 
injured by the employment of counter-irritants. Careful inquiry 
must always be made into the state of the urine, lest retention 
secretly accumulate to a dangerous degree. 

Op Convalescence. — The management of convalescence from 
fever is directed chiefly to two objects, the restoration of the 
strength, and the prevention of relapse. 

For the attainment of the former object, it is necessary to con- 
tinue the use of stimulants, and gradually to enlarge the allow- 
ance of food. In the generality of cases the quantity of stimu- 
lants must be reduced when convalescence is fairly established. 
They can seldom be dispensed with altogether ; but the large and 



TREATMENT. 231 

frequent closes administered advantageously throughout the earlier 
periods of fever are often observed at this time to cause marked 
reaction and even a return of the febrile symptoms, more especially 
frequent jarring pulse, dry, brown tongue, flushing of the face, 
and disturbed sleep. In some instances, however, convalescence 
is attended with an extraordinary tendency to fainting in concur- 
rence with constant general depression ; and here not only must 
stimulants be employed largely, but likewise they must be con- 
tinued very frequently, and with great regularity, otherwise the 
patient may perish in a state of deliquium. As to food, at first 
simple farinaceous articles and in the pulpy form are alone ad- 
missible ; afterwards more substantial articles of the like kind, but 
without fatty or aromatic seasonings, are allowable ; weak soups 
come next into requisition, and then eggs, or white fish with some 
simple sauce. Here the physician may pause for a time, before 
allowing solid animal food. When this is to be allowed, the broiled 
or roasted flesh of adult animals ought to be given in prefer- 
ence to chicken, veal, or lamb, which many absurdly prescribe at 
first under the notion that they are more digestible. To the gene- 
rality they are quite the reverse. In respect of the precise time 
for these changes, and their exact amount, special circumstances 
in each case must kivariably be the criterions. But the following 
rules should be constantly kept in view :— that the appetite shall 
always precede the supply by a day or two ; that much excite- 
ment after meals shall involve a diminution of allowances ; that 
in the case of the young, the meals shall be more frequent and 
more scanty than in adults ; and that a foul tongue or disturbed 
sleep is a sign of too abundant a supply. 

Some convalescents sleep almost constantly for some time. 
This is particularly observed of children. Many adults, on the 
contrary, are much harassed by night- watching, do not sleep above 
three hours in all daily, and have their slumber in short, broken 
snatches, which render the night extremely burdensome. Where 
exhaustion is thus occasioned, opiates are highly proper. But 
more commonly the patient is well refreshed with what sleep he 
does get, or is at once renovated by breakfast. In that case opi- 
ates are hurtful, and he must be content to watch till exercise re- 
stores natural sleep ; which will speedily happen when he is able 
to go out of doors. 

The most effectual preventive against relapse is the cautious 
regulation of the diet in the manner already directed. For the 
most frequent cause of relapse is some error in diet, particularly 
premature abundance of food ; and the usual manner in which the 
relapse is established is by the febricula which follows digestion 
being prolonged into confirmed pyrexia. Premature exposure to 
atmospheric vicissitudes, or inconsiderate fatigue, may have the 
same effect, and should, therefore, be guarded against. Exposure 
to atmospheric vicissitudes, however, is more apt to occasion acute 



232 CONTINUED FEVER. 

local inflammations than relapse ; and of the affections thus in- 
duced, neuralgic rheumatism, pneumonia, catarrh, and peritonitis 
are the most frequent. It is singular that convalescents from fever 
often retain for some time the same insensibility to cold which 
characterizes for the most part the state of fever itself. Some, on 
the contrary, are unusually alive to the impressions of cold, and 
these ought to be carefully protected against it. But many un- 
doubtedly show for a time a power of enduring cold, which is 
very surprising, and which protects them against the risk of local 
inflammations as well as of relapse. All convalescents from fever 
are apt to sutler most from cold during the night ; and it is at this 
time that local inflammations, especially rheumatism, are most 
commonly excited. 



IX. PROPHYLAXIS OF CONTINUED FEVER. 

As it has been shown, in a previous part of these remarks, to 
be not improbable, that the infection of fever is not active or ma- 
lignant in the generality of cases, it follows that much may be 
done by preventive means to lessen its dissemination. Inde- 
pendently of all theory in the matter, the extreme rarity of its 
propagation in the families of the middle ranks, where no doubt 
can exist of its having been introduced by infection, contrasted 
with the certainty of its diffusion in the families of the poor, or in 
fever hospitals, furnishes ample evidence how much may be 
accomplished by a skilful prophylactic system. 

The principal rules to be observed are the following : — The 
sick ought to occupy a spacious apartment, capable of being easily 
ventilated. In hospitals, fever wards ought to be far more spa- 
cious than they usually are in this country ; and they should have 
not less than twice the cubic contents of general wards. With 
the condition of free ventilation secured, complete separation in a 
family is not absolutely essential ; all unnecessary intercourse with 
the sick should, however, be of course avoided ; and in the case 
of the lower orders, where space and ventilation can scarcely ever 
,be attained, intercourse should be strictly limited to the personal 
attendance required for the patient's wants. The bed-clothes 
should be frequently changed ; and all unnecessary curtains and 
hangings removed from the apartment. Fumigations, once in 
universal use, are now generally abandoned; but unjustly, for 
they cannot fail to prove beneficial, either by their direct power 
of destroying animal effluvia, or by necessitating subsequent 
ventilation ; and hence, in the houses of the poor, at least, they 
should be practised once a-day if possible. Chlorine or nitric 
acid is most easily borne, and most readily obtained ; the former 
from milk of chloride of lime and sulphuric acid, the latter from 



TYPHOID FEVER. 233 

nitre and sulphuric acid, aided in their chemical action by mode- 
rate heat. The personal attendants of the sick ought not to be 
young people ; for it has been seen above that the chance of the 
disease being communicated, is, after thirty years of age, one-half 
what it is at twenty, and only one-third at forty. It is, of course, 
desirable to have attendants who are in some measure fortified 
by having had fever; but this security is seldom attainable. All 
unnecessary approach to the close vicinity of the sick should be 
avoided, and where a very close approach is inevitable, more 
especially when the bed-clothes are raised, the concentrated 
effluvia from the body should be avoidedlfor a few seconds, or 
the respiration suspended for a little, so that the emanations just 
let loose may become somewhat disseminated. Frequent change 
of the attendants is desirable ; and all excessive fatigues, particu- 
larly in night watching, must be shunned. The diet of the 
attendants should be good, and long fasts carefully guarded 
against. Advantage is probably derived, especially in the case 
of medical pupils, from vigorous exercise in the open air imme- 
diately after any unusual exposure to infection. 



234 



[CHAPTER III. 

TYPHOID FEVER. 

Syn. — See Syn. for Synochus, (p. 77.) 

The Continued Fever of the Middle and Northern States of 
this country is identical with that of the temperate latitudes of the 
continent of Europe — France, Germany, Sweden, &c. — and is 
frequently met with in Great Britain. The first attempt to prove 
the identity of the two diseases was made by Dr. Hale, of Bos- 
ton, in December, 1833.* Dr. Gerhard, of Philadelphia, indi- 
cated the points of resemblance, with greater precision, in Feb- 
ruary, 1835,t and Dr. Bartlett in June of the same year.J In 
June, 1838, Dr. James Jackson, of Boston, presented an elabo- 
rate memoir to the Massachusetts Medical Society, in which he 
asserted that "the symptoms were essentially the same, and the 
appearances after death precisely the same." A comparison of 
the description of the Typhous Fever of New England, by Dr. 
Nathan Smith,§ — who, after a practice of twenty-five years in 
that region, declared that it was the only form of continued fever 
he had ever met with — and the Typhoid Fever of Paris, by Cho- 
mel, will satisfy any one of the symptomatology of the two 
affections being precisely alike. 

This disease is known under a variety of names. It is called 
long fever *, nervous fever ', slow fever ; putrid fever i ; in New Eng- 
land it is usually termed typhus, or typhous fever. In accordance 
with Chomel, Gerhard, J. Jackson, and Bartlett, we prefer 
Typhoid Fever, as the appellation least liable to objection. 

I. DEFINITION. 

Typhoid Fever is an acute affection, whose anatomical charac- 
ter is an enlargement and special alteration of the intestinal fol- 
licles, accompanied by increase of volume, injection, softening, 
and occasionally suppuration of the corresponding mesenteric 
glands. The usual symptoms are, continuous fever, of variable 

* [Medical Magazine, December, 1833, Boston.] 

f [Am. Journ. of the Med. Sciences, Feb., 1835, Philadelphia.] 

i [Medical Magazine, June, 1835, Boston.] 

§ [Essay on Typhous Fever, New York, 1824.] 



ANATOMICAL CHARACTERS. 235 

intensity : stupor ; prostration ; pain and gurgling, on pressure, in 
the right iliac region ; an eruption, generally observed on the ab- 
domen and lower part of the thorax, of lenticular rose-coloured, 
slightly elevated papulae, disappearing on pressure ; meteorism ; 
diarrhoea ; pulverulence, or brownish coating of the interior of 
the nostrils. 



II. ANATOMICAL CHARACTERS. 

The constant lesions found in persons dying of typhoid fever 
are in the follicles of the small intestines, and mesenteric glands. 
The follicular alterations vary with the period of the disease. 
On examining the exterior of the small intestines of those who 
have died from the fifth to the eighth day, reddish, blue, or black 
opaque discolorations, sometimes covered with false membranes, 
and corresponding in situation to the diseased follicles, are visible 
along the curvature. On pressing these spots between the fingers, 
they are found to be hard and unequal. On opening the intestine 
by an incision along the mesentery, the agminate follicles (glands 
of Peyer) will be discovered in one or both of the following mor- 
bid conditions. 

1. Soft patches: — slight prominence; the mucous membrane 
a little softened, and the surface smooth, or mammillated. On 
cutting into the elevated patch, the mucous and subcellular tissues 
are moist, injected, and thickened. In some instances the gland 
has a reticulated appearance, the tissue resembling the paren- 
chyma of the cherry or plumb, the mucous membrane being soft- 
ened and readily detached. 

2. Hard patches: — more elevated than the preceding variety; 
elastic to the touch ; on division the submucous tissue appears to 
be transformed into a homogeneous matter of a pale yellowish 
hue, firm and friable. The surface is plane and shining. This 
species occurs in about one-third of all the cases ; usually in those 
which terminate at an early period ; and is supposed to be con- 
nected with the more severe and rapid forms of the disorder. 

3. Ulcerated patches — are observed after the ninth or twelfth 
day; there are two varieties: in one the ulceration begins in the 
mucous membrane, and extends to the gland, which it gradually 
destroys ; in the other the yellow matter of the gland first softens, 
the mucous membrane being consecutively involved, and easily 
detachable in shreds. Sometimes the transformation is so rapid, 
that the mucous membrane escapes, or is only partially implicated. 
The ulcers are commonly oval or elliptical ; in some the edges 
are hard, thick and salient; in others they are thin, the mucous 
membrane being undermined throughout the circumference. The 
base of the ulcer is brownish or slate colour ; granular or smooth; 



236 TYPHOID FEVER. 

or it may be formed by the muscular coat, somewhat hypertro- 
phied ; or by the peritoneum. Sometimes the peritoneum is perfo- 
rated by the extension of the ulceration, or from the formation and 
subsequent separation of an eschar ; these perforations are about 
a line or two in diameter, are single or multiple, are found in the 
lower part of the small intestines, and when the altered patches 
are but few. The number of diseased patches varies from one 
to thirty or forty; they bear no proportion, either in number or 
degree of alteration, to the symptoms during life. Usually, most 
or all of the alterations just described are found in the same sub- 
ject. The patches nearest the ileo-csecal valve are those most 
compromised. The transition from a diseased to a healthy state 
is generally abrupt, a healthy patch being rarely found between 
two diseased ones. Resolution takes place in the non-ulcerated 
patches, except in the reticulated variety of the soft patch, in 
which there has been loss of substance. In the ulcerated glands 
there is a gradual reparation of the lost substance ; the borders of 
the ulcer become effaced, whilst its base is covered by a thin, 
smooth, non-viilous pellicle, of a serous aspect, which at the end 
of several months undergoes mucous transformation.* 

* [Vogel has given the following description of the elevated patches previous 
to ulceration. " When portions of this mucous membrane were examined be- 
neath the microscope, the capillary vessels were observed filled with blood, 
which appeared as a red perfectly homogeneous fluid, none of the individual 
corpuscles being distinguishable ; it was still fluid, however, and could be 
squeezed out of the vessels by slight pressure, whereupon the unaltered indi- 
vidual corpuscles became apparent. The vessels were from l-100th to l-200th 
of a line in diameter; the mucous membrane, within which they ran, was colour- 
less, and presented a coarsely granular aspect. The epithelium was desquamated, 
but the cylindrical cells were found, both singly and arranged in groups, im- 
mersed in the surrounding mucous fluid. The mucous membrane and intestinal 
villi were in places tinged of a brownish-yellow colour by bile. Neither the 
membrane nor villi were much acted on by acetic acid; a few nuclei, about 
l-400th of a line in diameter, and provided with nucleoli, being here and there 
brought into view by this reagent. When portions from the middle of the 
patches, about half a line below the mucous membrane, were examined beneath 
the microscope, they were observed to be traversed by blood-vessels from l-100th 
to l-80th of a line in diameter; these vessels were filled with blood, which was 
still in a fluid state, and its eorpuscles unaltered. These portions themselves 
were composed almost entirely of a granulo-amorphous substance, between 
which were observed a few fibres of a fibro-cellular tissue, either separate or 
woven together into bundles. On treatment with acetic acid, a number of cell- 
nuclei came into view. Immediately beneath the patches was a layer of whitish 
cellular tissue [the lowest stratum of the submucous tissue], which, under the 
microscope, presented the ordinary appearance of fibro-cellular tissue. Almost 
all these fibres disappeared on treatment with acetic acid; a few only remained, 
and these became more distinct (nucleus-fibres]) Next beneath this layer of 
cellular tissue came the muscular coat of the intestine, there being no foreign 
substance between; the individual fibres of this coat were flat, and about l-500th 
of a line in diameter; they were rendered pale by acetic acid, whereupon their 
elongated nuclei came into view. Outside this coat was the peritoneal covering; 
its blood-vessels were very large, and visible to the naked eye, most of them 
being rectilinear, and running parallel to the axis of the intestines. This peri- 



ANATOMICAL CHARACTERS. 237 

The isolated follicles (glands of Brunner) frequently present 
the same alterations as the agminate; when affected they ap- 
pear as conical, rounded elevations, about the size of hempseed, 
and resemble large pustules. This condition is found only in the 
lower half of the ilium. 

The mucous membrane between the follicles is, in about four- 
fifths of the cases, more or less softened and injected. In those 
dying after the 20th day, a simple gray or slaty discoloration is 
seen only. 

The mesenteric glands are as constantly affected as the intes- 
tinal follicles. Their condition varies with the epoch of the dis- 
order. From the fifth to the thirteenth day they are merely 
enlarged, softened, and friable, and in hue from a delicate rose to 
a deep red. From the fifteenth to the twentieth this alteration is 
still more marked, and yellow points of suppuration are not un- 
frequently found disseminated through their tissue, but pus is 
rarely or never collected in an abscess. From the 20th to the 30th 
day they diminish in size and assume a violet or brownish colour ; 
after the 30th day they become gray, or slaty in hue, and more 
consistent. The degree of alteration seems to be in proportion to 
that of the intestinal follicles ; those glands nearest the caecum are 
the most affected.* 

toneal coat, when stripped off and examined beneath the microscope, was found 
to be composed of fibro-cellular tissue, the bundles of which ran in a direction 
parallel to that of the axis of the intestines. Between these fasciculi were ob- 
served blood-vessels, and numerous elongated caudate cells. The diseased 
thickening, therefore, was confined to the mucous membrane and the immedi- 
ately adjacent submucous tissue, and seemed to be the result of the deposition of 
a granulo-amorphous material within the healthy tissue of these parts."a] 

* [Most of the German pathologists — Rokitanskt, Engee, Vogel, &c. — 
maintain that in the course of typhoid fever a peculiar morbid matter is depo- 
sited in certain tissues and organs — particularly the mucous membranes, intes- 
tinal follicles, and mesenteric glands. They call it the "typhous material," and 
from the second to the eighth day is the period within which it begins to be de- 
posited. It may be either in a fluid or solid form. En-gee says the "fluid matter 
is a viscid opaque greenish-brown material, which, when allowed to remain at rest 
for some time, deposits an abundant sediment of epithelial cells, crystals of ammo- 
nia-phosphate of magnesia, and brownish flocculent coagula, whilst the fluid itself 
remains of a brownish or reddish colour, and contains a considerable quantity of 
albumen: it undergoes no other change but that of decomposition. The solid 
portion of the typhous product appears in the solitary and Peyerian glands of the 
small intestines, in the follicles of the large intestines, and in the mesenteric 
glands; it assumes the forms of these various parts in which it occurs, has a soft 
pulpy consistence, a grayish-red colour, and appears shortly after its deposition 
as a finely granular substance, mixed with blood-corpuscles, and seems to be 
chiefly composed of albumen."Z> Examined beneath the microscope, Vogee found 
this substance appearing "as an amorphous, slightly granular mass, of a brown- 
ish-white colour, within which a large quantity of small-sized cells were depo- 
sited. These cells had an irregular roundish form; the majority were below 

a [Erlauterungstafeln zur Pathologischen Hislolgie. Translated by W. S. Kirkes, Lond. Med. 
Gaz., vol. xxxvi., p. 1137.] 
b [Schmidt's Jahrbucher, No. 7. 1845. Lond. Med. Gaz. ; loc. cit.] 



238 TYPHOID FEVER. 

The alteration in the agminate and isolated follicles of the small 
intestines is so constant in typhoid fever, that it may properly be 
called its anatomical character, or organic characteristic. It is, 
nevertheless, true, that in scarlatina, cholera, and phthisis the in- 
testinal follicles, particularly Peyer's glands, undergo changes of 
structure, but which are not analogous to that observed in con- 
tinued fever. In scarlatina, Peyer's glands are said to be occa- 
sionally enlarged; but they never contain any yellow deposit, or 
ulcerate ; nor are the mesenteric glands implicated. In cholera 
they are frequently elevated, but much less so than in typhoid 
fever, and no further change occurs. The resemblance between 
the diseased follicles in phthisis and in continued fever is much 
greater. Instead, however, of a uniform layer of whitish deposit, 
the patches present on their surface a number of small elevations, 
like isolated tubercular follicles • in some cases a few only have 
ulcerated, in others there are extensive ulcerations, with a few of 
these tubercles on the edges. Where there are extensive ulcera- 
tions only, the induration and thickening of all the surrounding 
tissues distinguish their nature. Tubercular matter, too, is found 
in the mesenteric glands. 



III. SECONDARY LESIONS. 

The spleen is morbidly altered in most cases. It is ordinarily 
enlarged and softened, sometimes attaining four or five times its 
natural size. The mesocolic glands are occasionally in the same 
pathological condition as the mesenteric glands. Ulcerations of 
the mucous membrane of the pharynx and oesophagus are met 
with in a certain number of instances. The mucous membrane 
of the stomach is in many cases softened and thinned, and some- 
times ulcerated. The large intestine is diseased in a large ma- 
jority of cases; there is softening of the mucous membrane of the 
caecum and colon, with or without injection and thickening; hard, 
elevated patches, similar in character to those in the ileum, but 
smaller and not friable, are now and then met with ; ulcerations, 
independent of the follicles, exist often in the colon; they vary in 
diameter from 4 to 30 lines. The heart is softened in about one- 
half of the cases. These are the only lesions which occur with 
any frequency or constancy in typhoid fever, or appear to have 
any intimate relation to the phenomena of the disease. 

l-300th of a line in diameter; a few measuring from l-150th to l-200th of a line; 
some were distinctly nucleated. By treatment with acetic acid, the amorphous 
substance became transparent, and gradually disappeared, upon which very small 
cells (cell-nuclei?) with sharp outlines came distinctly into view, being unaf- 
fected by the acid. Both cells and blastema were dissolved by ammonia, and by 
caustic potash. The glands of the colon contained a substance exactly similar to 
that found in the mesenteric glands, and in those of the small intestines."] 



SYMPTOMS. 239 



IV. SYMPTOMS. 



Typhoid Fever varies in its mode of attack. The invasion is 
sometimes sudden and distinctly marked, occurring unexpectedly 
in the midst of health ; more frequently, it is gradual and insidious, 
some deficiency of bodily and. mental vigour, general uneasiness, 
and discomfort, pain and feebleness in the limbs, dizziness, dis- 
turbed sleep, loss of appetite, foul tongue, and even nausea being 
felt for several days— sometimes a week, or even longer. 

Accession often begins with intense frontal headache, on wak- 
ing in the morning; though sometimes there is only a sense of 
heaviness with vertigo ; a shivering fit, of variable intensity, soon 
follows, and is succeeded by increased heat of skin and frequency 
of pulse. A rapid and striking change in the physiognomy now 
takes place; the expression is besotted; the face is flushed; the 
hearing is dull, with ringing in the ears ; the intelligence is weak- 
ened ; and there is sensible muscular debility, shown by the stag- 
gering walk. Diarrhoea is often an early and prominent symptom, 
setting in with the fever, though obstinate constipation may exist. 
Epistaxis frequently takes place in the early days of the disease ; 
it is usually slight and recurrent, though sometimes excessive ; 
when trifling, and the patient is in bed, the blood escapes into the 
pharynx, and is rejected mixed with mucus as round and dark 
sputa. 

The disorder being now established, headache, if previously 
absent, is felt. There is considerable disturbance of the san- 
guiferous system, the pulse being large, resisting, and over 100. 
After two or three days it becomes softer, and quicker ; in young 
persons, females, and adult males of irritable constitutions, it often 
reaches or exceeds 120. The skin is dry, and pungently hot ; 
thirst is urgent and constant; the secretions of the mouth are thick 
and glutinous; the tongue, which was furred, becomes dry and 
clammy; or, coated at the base and in the centre, the edges being 
red. As the mouth dries the whole mucous membrane acquires 
a uniform red colour ; the lips crack, and the teeth look brilliant 
from the dried layer of mucus which covers them. Anorexia is 
complete; and there is often nausea, with vomiting of bitter and 
greenish matters. The diarrhoea is persistent, four or five thin 
yellow evacuations taking place daily, attended with pains in the 
bowels ; the abdomen is distended and tympanitic ; there is pain 
on pressure, around the umbilicus, and pain and gurgling on 
pressure in the right iliac region. The spleen is generally en- 
larged, shown by increased dullness on percussion in the left 
hypochondrium; it sometimes extends below the margin of the 
ribs. Slight cough generally exists from the outset, with the ex- 



240 TYPHOID FEVER. 

pectoration of viscid, greenish sputa, and quickened respiration. 
Sonorous and sibilant rhonchi are found, unequally diffused 
through both sides of the chest, although more marked inferiorly 
and posteriorly. We have seen extensive double bronchitis in 
this disorder without a single objective symptom and only dis- 
coverable by physical exploration.* 

From the 5th to the 9th day the peculiar typhoid eruption ap- 
pears. It consists in minute rose-red spots, disappearing on pres- 
sure, from half a line to two lines in diameter, of a circular form 
and slightly raised above the level of the skin ; generally found 
on the abdomen, and lower part of the chest, they are sometimes 
met with on the back, arms, and thighs. The eruption does not 
make its appearance on all the points at once ; nor is its duration 
always the same ; in some cases it disappears entirely after two 
or three days ; at other times it persists during twelve or fifteen; 
in the latter case it consists of several successive crops, as each 
rose spot is visible for three or four days only, and sometimes less. 
Before fading, it generally becomes darker in its hue. 

The symptoms of the nervous centres now increase ; the mus- 
cular debility is excessive; the patient lies motionless on his back,t 
or there is a tendency to slide down in the bed ; he seems perfectly 
indifferent to his situation ; his features are immovable ; he de- 
sires to be let alone ; questions, when heard and understood, are 
slowly and reluctantly answered, and often with evident ill- 
humour, — the replies being brief and dry ; the perception of sur- 
rounding objects is vague ; women make slight or no efforts to 
resist exposure of their persons ; the eyes are injected and bril- 
liant, but have an expression of unusual stupidity; sleep isunre- 
freshing, and disturbed by vivid and startling dreams. The head- 
ache diminishes, or ceases entirely about this period. The face is 
swollen, and the cheeks of a lurid red. The pulse is soft, rapid, 
and often irregular ; and diminution in the intensity and duration 
of the first sound of the heart, with sometimes its total extinction, 
is met with in many cases. This phenomenon, first mentioned by 
Dr. Stokes, of Dublin,^ has since been observed by Dr. Pennock, 
of Philadelphia,§ Huss, of Stockholm, || and the writer. There is 
complete deafness ; with irregular and involuntary movements of 
the tendons of the arms and hands; convulsive twitches of the 
nose and upper lip ; carphology ; and great wakefulness. Delirium 
generally occurs during the second week, and is first manifested 
at night, the usual period of febrile exacerbation ; it is peculiar, 

* [Medical Examiner, vol. vi., p. 294.] 

f ["// git, mais il ne couchepas" Quelqnes Reflections sur la Fievre Typhoide, 
parle Docteur Sandras.— Gaz. Med., 1845.] 

* [Dublin Med. Jaurn., March, 1839.] 
§ [Med. Examiner, vol. vi., p. 123.] 

B [Gazette Medicale — Nos. 15 to 16 inclusive — 1845.] 



SYMPTOMS. 241 

usually tranquil, and rambling; though sometimes it is violent, 
with a disposition to talk loudly, leave the bed, and roam about. 
Sometimes the patient, at this period, falls into a drowsy state — 
the coma somolentum of authors— from which he cannot be 
roused except for a few moments. There is now an aggravation 
of all the general symptoms; the tongue becomes dryer, browner, 
fissured, and trembling; sometimes it is of a bright red colour 
and smooth, as if covered with a coat of varnish. The mouth 
and teeth are crusted with darksordes; there is great difficulty, 
or even inability, to swallow or protrude the tongue ; this may 
arise from paralysis of the muscles of deglutition, but often the 
half-dried mucosities collect around the base of the tongue and 
render the attempt painful or impossible. The nostrils become 
obstructed by dried mucus or blood, and the breathing has a pe- 
culiar whistling sound. The pulse is quick and irregular ; diar- 
rhoea is abundant, and the stools are often passed involuntarily ; 
there is retention of urine; and hemorrhages may occur from the 
nose, bowels or uterus. Concurrently with these symptoms, pete- 
chias are sometimes observed. A peculiar odour is exhaled from 
the body, by some said to resemble that from mice.* The heat of 
the body is acrid. Sloughs are apt to form, for in no acute disease 
is ulceration of the integuments more common than in this. 'They 
occur in about one-fifth of the cases; and are generally found on 
those parts of the body exposed to pressure — as the sacrum, occi- 
put, heels, trochanters, &c; or, gangrene may attack blistered 
surfaces, or leech bites, or those portions of the skin where sina- 
pisms have been applied. Sometimes spontaneous sphacelation 
takes place. Dr. Grisolle has seen gangrene of the integu- 
ments of the thigh, scrotum, foot, and lower lip supervene in the 
course of typhoid fever, without any appreciable cause. Dr. 
Roupell relates an instance of the entire soft parts of both legs 
becoming gangrenous, so as to render necessary the removal of 
the bones by the saw. Besides the lenticular rose-spots, or ty- 
phoid eruption, and petechias, small demi-hemispherical, trans- 
parent vesicles are sometimes observed in the course of the 

* [Dr. TCichter, of Dnsseldorf, relates a case in which ammonia was excreted 
by the skin. Three days before death, when the patient was comatose, the face, 
hair of the head, and beard became covered with a whitish shining matter resem- 
bling spermaceti. On examination, the face was found sprinkled with minute 
spots of a whitish substance, which on being removed, left the skin with a punc- 
tated appearance. The excretion continued until death, after which the thighs 
were found covered with small needle-like crystals. Chemical analysis proved 
that the excreted matter was alkaline and ammoniacal, and contained, in addi- 
tion, a whitish yellow substance soluble in ether.a Liebig has found ammonia 
in the air of the vicinity of fever-patients ; and Donxe and Prout ascertained 
that the rhomboidal prisms in the urine and feces, consist of the phosphate of 
ammonia and magnesia.] 

o. Oesterreich. Med. Wocliens. 1843, p. 437. Bennett's Report on the Progress of Pathology, 
&c. B. k. F. M. Rev., vol. xx., 1845. 

16 



242 TYPHOID FEVER. 

second week. When viewed obliquely they have a brilliant 
appearance, but when looked at perpendicularly to their axis, 
escape notice. They are readily distinguished by the touch; they 
appear at first on the sides of the neck, and in the folds of the 
arm-pit and groin, from thence in some cases extending to the 
trunk and limbs. Though not so intimately connected with the 
disease as the rose spots, they are much more frequent in it than 
in any other with which it might be confounded. 

Towards the close of the second week, or beginning of the 
third, a decided change or " turn" takes place. If the attack is 
to terminate in recovery, the symptoms abate; the expression 
of the face is more natural; the pulse slower and steadier: the 
patient takes notice of what is passing around ; the skin becomes 
moist, soft, and of natural temperature ; and the tongue cleans 
rapidly. Some critical evacuation, as sweating, not unfrequently 
precedes this amelioration. If, however, the disorder is to prove 
mortal, there is a decided increase in severity of the symptoms, 
or new ones supervene. 

Typhoid Fever may terminate fatally in four different ways. 
Drs. Alison and Williams have both particularly insisted on 
the importance of studying the modes of death in continued fever, 
from its direct practical bearing; for by anticipating the kind of 
fatal termination most probable in each case, we may be guided 
to a rational and successful treatment. 

1. Necrsemia, or death beginning ivith the blood, is the most 
usual fatal termination of Continued Fever. The symptoms called 
typhoid, and lately described, belong especially to this class of 
death ; the heart loses its power, the pulse becoming fearfully 
rapid, weak, and unsteady ; the whole surface has a congestive 
appearance, the hue being dusky or livid ; the brain becomes in- 
active, as the direct result of the noxious poison circulating in 
the blood, and stupor ensues; the medulla is torpid, and respi- 
ration and excretion are imperfect; there is intense prostration of 
strength; half closed eyes and dilated pupils; molecular nutrition 
ceases; and molecular death follows closely on somatic death, or 
may even precede it, as exhibited in the sloughy ill-conditioned 
ulcers, and putrid odours.* 

2. Death by Coma resembles that by Necrsemia and is often 
confounded with it. It results from mechanical pressure on the 
brain, from effused lymph, or serum. Death by coma begins at 
the brain, the symptoms being those of interrupted function of 
the cerebrum, insensibility and suspension of voluntary motion. 
Stupor comes on gradually and deepens; symptoms of impaired 
excito-motory function appear ; the breathing is stertorous, and 
imperfect ; deglutition becomes impossible ; the pupils are dilated; 

* [Clymer's Edition of Williams' Principles of Medicine, p. 373.] 



SYMPTOMS. 243 

and the sphincters are relaxed, involuntary discharges of urine 
and feces taking place. 

3. Death from apncea, or death beginning- at the breathing 
apparatus, is partly due to the enfeebled state of the circulation, 
and want of power in the heart to propel the blood through the 
lungs; but partly, also, to the congested state of those organs 
from bronchitis or pneumonia. It is rarer than that by necraemia 
or coma, but is not unfrequent, and is often mingled with coma. 
The phenomena are those of asphyxia. 

4. The mode of death by Asthenia or syncope, is not common 
by itself, though sometimes, when the disease is of long continu- 
ance, death does apparently take place from mere cardiac debility. 
It happens in those who have been subjected to a debilitating 
treatment, and who have not been properly nourished during the 
disease. 

State of the Blood. — The condition of the blood in typhoid 
fever has been studied with a good deal of care within a few years. 
Andral,Bouillaud, Forget, Simon, and a number of others have 
published the results of these investigations. " The blood in typhoid 
fever," the late Dr. Franz Simon remarks,* "exhibits the characters 
of hypinosis perhaps more distinctly than in any other affection : 
but the statements regarding its qualitative and quantitative com- 
position are still very contradictory, arising, probably, in part, from 
its varying in the different stages: thus, in the period of excitement, 
it may incline towards a state of hyperinosis ; in the stage of de- 
pression, the fibrin gradually decreases ; and lastly, in the stage of 
collapse, the quantity of blood-corpuscles and of solid constituents 
decreases so remarkably, that in the case of putrid typhoid fever 
the blood (in consequence of the liquor sanguinis being too watery, 
and deficient in salts), assumes the state of spansemia. The same 
appears to occur in petechial typhus. One source of difference is 
therefore evidently dependent upon the stage of the disease at 
which the blood is taken : the presence of any inflammatory symp- 
toms will also modify its constitution. 

" The blood in typhoid fever is found to be very deficient in 
fibrin, and frequently also in albumen : it coagulates imperfectly, 
and often remains in a semi-fluid state : the clot is soft, friable, of 
a very dark, almost black red colour, and is very rarely covered 
with a buffy coat : this form of blood becomes putrid sooner than 
the healthy fluid. 

" I have made two analyses of the blood in rather mild forms of 
the disease. The results do not by any means give a good idea 
of hypinosis sanguinis. 

* [The Chemistry of Man : Translated by Thomas E. Day, &c. p. 236. Phil., 
1845.] 



244 



L 


TYPHOID FEVER. 










Analysis 29. 


Analysis 30. 


Water , 


~ 


- 


816-875 


792-340 


Solid residue 


- 


- 


183- 125 


207-660 


Fibrin 


- 


- 


2-525 


2010 


Fat 


. 


- 


2-233 


2-200 


Albumen . - 


. 


- 


90-650 


80-330 


Globulin 


. 


- 


75-205 


99-510 


Use matin 


- 


- 


3-985 


5-300 


Extractive matters 


and salts - 


- 


9-678 


12-670 



" The disease diagnosed in both instances (which occurred in 
our hospital) was dothinenteritis. In both cases venesection was 
ordered at an early stage of the disease, when there was a good 
deal of vascular excitement present, which may account for the 
partial decrease of the fibrin and increase of the corpuscles. The 
blood in Analysis 29 was taken from a man 30 years of age; the 
tongue was furred, abdomen tender on pressure, mind tolerably 
clear ; pulse rather full, 95 in the minute. The blood in Analysis 
30 was taken from a man 38 years of age ; in whom there was a 
good deal of nervous excitement, giddiness, and buzzing of the 
ears ; the abdomen was tender on being pressed, the tongue thickly 
coated, and the pulse quick, rather hard and full. Both cases 
turned out favourably. " 

In an analysis of the blood in typhus abdominalis, made sub- 
sequently to the publication of his Chemistry, Simon found, water 
887-5, solid constituents 112-5, fibrin none, albumen 54, haemato- 
globulin 47-25. 

The most comprehensive researches on the blood in typhoid 
fever are those of Andral and Gavarret, who made 50 ana- 
lyses of blood taken from 20 persons suffering under this affection. 
The following are their principal results: 

The fibrin never rises perceptibly above the normal standard in 
true typhoid fever. It often remains at the normal height, and is 
still more frequently below it. In inflammatory disorders it is 
pretty clear that the fibrin increases with the intensity of the dis- 
ease ; here we observe just the reverse: the fibrin decreases in 
proportion to the advancement of the disorder. Andral and 
Gavarret observe that this cannot be ascribed to the repeated 
bleedings, or to the continual low diet, for these circumstances 
induce no change in the amount of fibrin in other diseases. As 
soon, however, as any symptoms of convalescence appear, the 
fibrin begins to increase, even before the organization could con- 
tribute a supply by increased nutriment. This continues to be 
the case during the progress of convalescence, and as the patient 
improves the corpuscles simultaneously decrease. 

In inflammatory diseases there is a general tendency to dimi- 
nution in the corpuscles: here we have just the reverse, for the 
more frequently we analyze blood soon after the outbreak of the 



SYMPTOMS. 245 

disease, the more frequently shall we find instances in which the 
corpuscles, instead of being diminished, are considerably increased, 
and, even in the more advanced stages, the amount of the corpus- 
cles is frequently found to exceed, or at any rate to equal the nor- 
mal quantity. The absolute increase of the corpuscles is not, 
however, so decided as the increase of the fibrin in inflammatory 
diseases ; neither is it so essential a condition for the existence of 
the disease, for even in those cases in which the amount is much 
increased at the commencement of the disorder, it may become 
diminished during its course, and even when it is getting more 
severe. However, when the absolute quantity of the corpuscles 
is diminished, its proportion to the fibrin is still greater than is 
ever observed in the normal state. 

The leading characteristic of the blood in this disease is the 
decrease of the fibrin, which diminishes in proportion to the vio- 
lence of the attack, and from which another character is derived, 
namely, the increased amount of corpuscles. During the early 
period the diminution of the fibrin is not absolute ; it is only rela- 
tive in relation to the corpuscles ; but as the disease approaches 
its height, the diminution becomes absolute. 

Researches instituted in mild cases may give perfectly negative 
results. Their maximum of fibrin was 3-75 their minimum -9 It 
is true that in one case they found 4-2 of fibrin, but the blood was 
taken during convalescence. The maxima, minima, and average 
results of 41 analyses are given in the following table : 













Solid residue 




Water. 


Solid residue. 


Fibrin. 


Blood-corpuscles. 


of serum. 


Maximum 


862-3 


243-7 


4-2 


149-6 


980 


Minimum 


756-3 


137-7 


0-9 


66-7 


66-8 


Average 


796-0 


204-0 


2-6 


116-0 


77-9 


Healthy blood - 


790-0 


210-0 


30 


127-0 


80-0 



This average of 41 analyses (some have been omitted, as giv- 
ing no definitively clear result), does not give the general charac- 
ters of the blood, as it is expressed in the majority of the analyses. 
The amount of fibrin is certainly less than in healthy blood, but 
the corpuscles do not attain to their normal height. If, however, 
the fibrin is estimated at 3-0, the proportion of the corpuscles is 
134, which is higher than in healthy blood. The quantity of the 
residue of the serum, and of solid constituents generally, approxi- 
mates closely to the normal standard. The inorganic constituents 
of the residue of the serum amount, on an average, to 7-6^, which 
is very little lower than the corresponding number in erysipelas 
or rheumatism. 

The following table contains the numerical results of Andral 
and Gavarret's researches on the blood in typhoid fever. In 
order to make the proportion of the corpuscles to the fibrin more 
striking, the numbers obtained from the analyses are not merely 



246 



TYPHOID FEVER. 



given, but the relative numbers on the assumption that the fibrin 
is constantly represented by 3. 



Date of 

Venesection, attack. 



1st Case 



Solid 
Water, constituents. Fibrin. 



2d " 
3d " 

4th " 



5th 



6th " 



7th 



1 


5 


756-3 


2 


7 


769-7 


3 


8 


785-2 


4 


10 


798-6 


5 


15 


827-4 


1 


1 


819-7 


1 


5 


752-9 


1 


7 


766-5 


2 


9 


777-6 


3 


12 


782-1 


1 


8 


767-6 


2 


10 


777-3 


3 


11 


782-4 


4 


14 


791-7 


1 


9 


769-5 


2 


10 


784-7 


3 


12 


804-3 


4 


15 


8311 


5 


33 


845-5 


1 


9 


810-3 


2 


10 


816-2 


3 


12 


825-6 


4 


17 


836-8 


5 


24 


847-8 



243-7 
230-3 
214-8 
201-4 
272-6 
180-3 
247-1 
233-5 
222-4 
217-9 
232-4 
222-7 
217-6 
208-3 
230-5 
215-3 
195-7 
168-9 
154-5 
189-7 
183-8 
174-4 
163-2 
152-2 



2-3 
21 
1-8 
1-3 
10 
0-9 
2-4 
25 
3-7 
3-6 
50 
5-4 
50 
4-0 
3-6 
2-9 
2-3 
1-9 
3-7 
3-4 
3-5 
2-3 
17 
21 



Blood- 
corpuscles. 

145-3 

135-8 

126-2 

116-2 

91-7 

931 

146-7 

143-6 

136-2 

134-5 

139-3 

129-7 

1271 

123-6 

149-6 

125-3 

123-7 

103-0 

79-6 

102-4 

105-0 

93-9 

86-3 

760 



Blood- 
corpuscles. 
(Fibrin=3.) 

180-0 

1930 

210-0 

268-0 

273-0 

310-0 

183-0 

1720 

110-0 

1120 

830 

720 

76-0 

920 

124-0 

129-0 

161-0 

163-0 

64-0 

90-0 

900 

1220 

152-0 

108-0 



Residue 
of serum. 

961 
92-4 

86-8 
83-9 
79-9 
86-3 
98-0 
87-4 
82-5 
79-8 
88-1 
87:6 
85-5 
80-7 
77-3 
87-1 
69-7 
640 
71-2 
83-9 
79-8 
78-2 
75-2 
74-6 



From these two columns of the blood-corpuscles we see that 
the decrease of the fibrin is almost always connected with the 
increase of the corpuscles, so that the proportion between the two 
gradually differs more and more from the normal mixture. The 
exceptions to this rule are caused either by some inflammatory 
complication, as in the fifth case, where an acute attack of bron- 
chitis accompanied the fever, or by the patient being in a state of 
convalescence as in the fifth analyses, in cases 6 and 7. Andrajl 
and Gavarret offer no explanation of the peculiarities in the 
fourth case. 

The solid constituents of the blood are more frequently above 
than below the normal standard, but the proportion is a fluctuat- 
ing one, and dependent, as we shall presently see, on the progress 
of the disease. 

Lecanu has analyzed the blood of two persons suffering from 
typhoid fever. As he did not determine the amount of fibrin, the 
proportion of that constituent to the corpuscles cannot be shown. 
Their absolute quantity is less than in normal blood. Lecanu 
also states, that he thinks that a paucity of corpuscles may be in- 
ferred from the smallness and friability of the clot, a statement at 
variance with the researches of Andral and Gavarret. 



SYMPTOMS. 247 

Lecanu also found a diminution of the solid constituents gene- 
rally: — 



Water 


- 


805-20 


795-88 


So] id residue 


- 


194-80 


204-20 


Blood-corpuscles 


- 


11500 


10500 


Residue of serum 


- 


79-00 


99-12 



Chomel does not consider that the diminution of fibrin is a 
specific character of the blood in typhoid fever, because he found 
that in 6 out of 30 cases the blood formed a solid clot, covered 
with a burly coat, but differing in thickness and colour from the 
inflammatory clot ; while in 2 cases there was a slight film, be- 
neath which the clot was diffluent; in 2 the blood remained per- 
fectly fluid and slightly lumpy, and in 20 the blood formed a firm 
clot, but no buffy coat. The blood in all these cases was taken 
during the first or the commencement of the second stage, never 
in the third. The peculiarities in Chomel's statement may be 
partly due to the blood being taken at a period before the fever 
had reached its height, partly to the association of some inflam- 
matory symptom, or to a more synochal type of the disease. 

According to Jennings,* the blood in the first stage of typhoid 
fever (depression) is generally thick and dark; it coagulates ra- 
pidly and forms a soft, large, dark-coloured clot. In the second 
stage (excitement) it flows readily, is of a scarlet colour, does not 
coagulate so quickly as, and forms a more solid clot than the 
former. It is also occasionally covered with a slight buffy coat. 
In the third stage (collapse) it flows very readily, is thin, watery, 
and of a dark colour: the clot is loose and flocculent, and occa- 
sionally appears more as a sediment of colouring matter than as 
a clot. In thoroughly developed typhus Dr. Armstrong found 
the blood of the temporal artery as dark as that of the vein. Dr. 
Clanny also states that the watery portion of the blood increases 
with the intensity of the disease, and that not merely the solid 
constituents generally, but also the salts and carbonic acid are 
diminished. The water begins to decrease, and the solid consti- 
tuents to increase in favourable cases after 12 or IS days. Ac- 
cording to Stevens, the salts of the blood (especially the chloride 
of sodium) are diminished in all typhoid fevers. 

Becquerel and Rodier have analyzed the blood of ] 3 per- 
sons attacked with typhoid fever, 11 men and 2 women. Of the 
11 men, 6 were bled once, 4 twice, and 1 thrice; of the 2 women, 
1 was bled once, and 1 thrice. 

The following table exhibits the mean composition of the blood 
of the male patients, obtained at the first venesection : 

* [Course of Lectures on the Physiology and Pathology of the Blood, by H. 
Axcell. The Lancet, 1840, p. 338.] 



248 TYPHOID FEVER. 

Density of defibrinated blood - - - 1054-4 

Density of serum ----- 1025-4 

Water _..--- 797-0 

Solid residue ----- 203-0 

Fibrin 2-8 

Fat 1-773 

Albumen - - - - - 64-8 

Blood-corpuscles - - " - - - 127-4 

Extractive matters and salts - 6-3 

The salts consisted of: 

Chloride of sodium ----- 2-9 

Other soluble salts - - - - - 2-5 

Phosphates ------ 0-497 

Iron ------ 0-555 

The fibrin varied considerably, the maximum being 4-9, while 
in three cases it was considerably below the normal standard. 
The albumen and blood-corpuscles were, in most instances, di- 
minished. 

Four of the same men were bled a second time, and the follow- 
ing table gives the mean results of the blood obtained in these four 
cases, on both occasions : 

1st Venesection. 2d Venesection. 

Density of defibrinated blood - 
Density of serum - 

Water - 

Solid constituents - - 

Fibrin - 

Fat 

Albumen - 

Blood-corpuscles - 

Extractive matters and salts 

The salts consisted of 

Chloride of sodium - 

Other soluble salts -..-.- 

Phosphates . - . . - 

Iron - - - - - 

A comparison of the two columns shows that the blood ob- 
tained by the second venesection contains a considerably smaller 
mean amount of fibrin than the blood previously taken. The 
albumen and corpuscles are likewise diminished. 

The case in which venesection was performed three times 
offered no peculiarity ; neither did the analyses of the blood of 
the two women. 

In all these analyses the clot was found to present no striking 
peculiarity. There was none of the softness and diffluence on 
which the older writers laid so much stress. 

Scherer has analyzed the salts of the blood in a case of typhoid 
fever. In 1000 parts of blood there were 176-3 of solid residue, 



10540 


1051-4 


10250 


1024-7 


801-0 


814-5 


1990 


185-5 


2-3 


13 


1-527 


1-408 


64-4 


620 


124-5 


113-5 


60 


7-3 


3-6 


3-5 


2-6 


2-7 


0-544 


0-255 


0-581 


0-519 



CONVALESCENCE. 249 

which on incineration yielded 11-92 of fixed salts. These con- 
sisted of: 



Chloride of sodium 


6-82 


Carbonate of soda _ 


1-41 


Sulphate of soda 


0-84 


Phosphate of soda 


0-94 


Carbonate of lime 


0-16 


Phosphate of lime 


0-60 


Sulphate of lime 


0-22 


Peroxide of iron 


0-60* 



State of the Urine. — It appears from the observations of 
Schonlein and Simon that the urine in the regular course of ty- 
phoid fever, is at first dark and very acid, subsequently neutral 
and even alkaline, and again acid at the commencement of con- 
valescence. The following observations are recorded by Simon 
in his Animal Chemistry. In one case the urine became faintly 
alkaline on the seventh day after admission ; it remained either 
alkaline or neutral for seven or eight days; and then became 
faintly acid and gradually clearer, as soon as the patient exhibited 
symptoms of convalescence. 

In a second (very severe) case the urine remained acid till the 
twenty-first day ; it then became neutral, and afterwards alkaline, 
for the space of ten or eleven days, when it returned to its nor- 
mal reaction. 

In two other cases the urine became alkaline previously to the 
fourteenth day of the disease ; in one of them the secretion was 
so thoroughly saturated with carbonate of ammonia, and evolved 
so disgusting an odour, as to be perceptible over the whole ward. 
This urine deposited a considerable sediment of pus or mucus, 
mixed with the phosphates of lime and magnesia, and effervesced 
briskly on the addition of an acid. In one of these cases the 
urine remained alkaline for fourteen, and in the other, for twenty- 
one days, before it resumed its acid reaction. Both cases reco- 
vered. 

It is worthy of notice, that a deposition of urate of ammonia 
not unfrequently precedes the occurrence of alkalinity and the 
appearance of the earthy phosphates, which, as Schonlein re- 
marks, may be regarded as the precursors of a favourable 
change. 



II. CONVALESCENCE. 

The duration of convalescence is generally proportionate to 
the gravity of the attack ; where this has been severe and pro- 
tracted, and the prostration extreme, strength is slowly gained, 

• [Simon's Animal Chemistry, p. 242. Phil., 1845.] 



250 TYPHOID FEVER. 

and amendment is very gradual. Emaciation is often excessive 
at the commencement of convalescence. Painful oedema of the 
lower extremities, and loss of the hair of the head are frequent 
occurrences after typhoid fever. Where the debility is great, the 
mental faculties are often impaired; and this condition exists 
until recovery is completed. The hearing, in many instances, 
remains dull for some time ; especially in those cases where there 
has been purulent discharge from the meatus. If perforation of 
the membrana tympani has taken place, hearing is rarely re- 
stored perfectly. Convalescence is sometimes suddenly arrested 
by symptoms of gastric distress: the digestion becomes laborious, 
the skin hot, and the pulse quick ; proceeding from some irregu- 
larity of diet, they subside, usually, after a day or two. Abscesses, 
eschars, and erysipelas often render convalescence tedious. 

III. VARIETIES. 

Typhoid Fever recurs under various forms, according to the 
presence, or absence, or prominence of certain symptoms. Indi- 
vidual cases and entire epidemics are sometimes so mild, that 
not a single severe symptom is present from the beginning to 
the end. The subjective phenomena are so insignificant as often 
to escape notice. Between the mild and latent forms, every 
variety of gradation is observed. Sometimes the general symp- 
toms common to inflammatory affections are unusually distinct 
at the commencement; but they seldom last beyond a few days, 
when they change to the adynamic or ataxic. This form is 
most frequently seen in winter, and in young persons of a san- 
guine temperament. The Adynamic form is the most common; 
it is marked by the existence of extreme prostration, occurring 
from the beginning, or supervening in the course of the attack. 
The progress of this variety is generally slow, the disease often 
being prolonged beyond the fourth week. In the ataxic form the 
nervous system appears to be early and deeply interested. 



IV. MARCH. 

The progress of Typhoid Fever is regular and progressive. 
Sudden changes rarely happen. Daily exacerbations, generally 
at night, are common, but the remissions are not decided, or 
lasting. 

V. DURATION, &c. 

The mean duration of this disorder is from eighteen to thirty- 
two days. Convalescence rarely happens before the fourteenth 



COMPLICATIONS. 251 

or sixteenth day ; although exceptional cases are mentioned, 
where it was established on the eighth or ninth day. The writer 
has seen it in several cases extend beyond the fortieth day. Death 
is infrequent before the seventh day ; most fatal cases terminate 
somewhere between the fifteenth and twenty-fifth days. 

Relapses. — Most authors agree that relapses are by no means 
infrequent. 

Recurrence. — Until lately it has generally been held by writ- 
ers on typhoid fever that it never attacks the same person twice. 
This opinion has been recently modified by the publication of 
several undoubted instances of recurrence. Dr. Louis, in a late 
session of the French Academy of Medicine, stated that he had 
seen a well-authenticated case of a second attack of typhoid fever. 
It is, however, no doubt very rare. 



VI. COMPLICATIONS. 

The most frequent complications of Typhoid Fever are perfo- 
ration of the intestine, and consecutive peritonitis ; hemorrhage ; 
inflammations of the respiratory organs ; otitis ; erysipelas of the 
face ; abscesses ; &c. 

1. Consecutive Peritonitis is an accident of the gravest and 
most fatal character. At the moment of its occurrence a sudden 
and severe pain is felt by the patient at the seat of the perfora- 
tion, and which soon extends to the whole abdomen. Where 
there is extreme debility, or considerable stupor, this symptom 
may be very imperfect. When present, pressure on the abdo- 
men is intolerable, a general chilliness is felt, the features rapidly 
change, and there are vomiting and constipation. Death takes 
place from six to forty hours ; though Louis has known an in- 
stance where the patient survived seven days. Perforation occurs 
suddenly ; more frequently in mild than severe cases ; and gene- 
rally without any appreciable cause. 

2. Hemorrhages. — Intestinal hemorrhage is frequent in the 
adult; it is never critical ; usually causes great prostration; and 
sometimes death. It is sometimes abundant, the blood being 
pure, fluid, or in dark clots ; at other times the quantity is small, 
and it is intimately mixed with the fecal discharges. Hemor- 
rhage, alarming as to quantity and effect, occasionally occurs from 
the uterus. In such cases, the quantity is generally considerable. 

3. Pneumonia is met with in about one-seventh of all the 
cases. It generally occupies the base of one or both lungs. It is 
more congestive than inflammatory, and is very often latent, 
Bronchitis, to a greater or less degree, is invariably present. 



252 typhoid fever. 

4. Erysipelas op the Face, Otitis, Parotitis, and Ab- 
scesses, sometimes, though rarely occur. We have seen the 
trunk and extremities covered with successive crops of furuncles, 
lasting for two weeks, and retarding convalescence. 



V. DIFFERENTIAL DIAGNOSIS. 

Although there is no one, or even two or three symptoms 
actually pathognomonic of typhoid fever, there are certain phe- 
nomena which occur with such constancy, and with such greater 
frequency in its course than in any other disorder, that in most 
cases, when fully established, a certain and timely diagnosis may 
be made. When a febrile affection, of several days' duration, is 
attended with early and marked prostration of strength, a puzzled 
and stupefied physiognomy, epistaxis, diarrhoea, meteorism, pain 
and gurgling, on pressure, in the right iliac region, diarrhoea, an 
eruption of lenticular rose papulae on the chest, belly, or back, 
sudamina, enlarged spleen, diffused bronchitis, and a pungent 
heat of the surface, — there can be no doubt, with such an assem- 
blage of symptoms, of the nature of the affection. But most, or 
all of these may be absent ; for in the mild and latent forms of 
the disease the subjective symptoms are few, ill-defined, unsatis- 
factory, or even null. In such cases a diagnosis becomes very 
puzzling and difficult, and a positive opinion should be given 
with great caution. Still, careful observation, and a familiarity 
with the disease will frequently enable the physician to decide 
positively. The duration of the attack is, under such circum- 
stances, a valuable element in the diagnosis. When a febrile 
disorder, accompanied with muscular debility, exists beyond a 
week, in a person between fifteen and forty, and no local cause 
can, on careful examination, be ascertained, there is good reason 
to fear the existence of typhoid fever. An analysis of the blood 
might be resorted to in doubtful cases, to decide whether there 
was any local inflammation, — the observations of Andral and 
others having proved the constant increase of fibrin in all the 
phlegmasia?, whilst in typhoid fever, it is either stationary or 
actually diminished. The age will often materially assist us, — 
for, as will be presently shown, typhoid fever is comparative- 
ly rare after forty. When not seen until an advanced period, 
and no previous history can be obtained, it may be confounded 
with other disorders, in which typhoid symptoms are common 
— as puerperal fevers, the last stage of dysentery, glanders, puru- 
lent infection, and renal diseases : but further investigation of the 
circumstances of the case will speedily clear up the diagnosis. 
The visceral inflammations of old men are often latent, and ac- 



PROGNOSIS. 253 

companied by extreme debility ; here the age, and careful physi- 
cal exploration will generally elucidate the case. The prodromes 
of the exanthemata — variola, measles and scarlatina — resemble 
often those of typhoid fever; but the initial phenomena are rarely 
adynamic, which circumstance, with the prevalent epidemic con- 
stitution, and the characteristic symptoms of each, will prevent an 
erroneous diagnosis. From enteritis it is essentially dissimilar, as 
shown by the subjoined tabular view. 

Typhoid Fever. Enteritis. 

Diarrhcea frequent; often slight. Diarrhcea constant and copious. 

Meteorism frequent. Rare. 

Pain and gurgling in right iliac region None, 
on pressure. 

Spleen enlarged nearly always. Spleen never enlarged. 

Headache in most cases, and often Headache rare and slight, 
intense, and from the outset. 

Muscular debility from the outset. No prostration until the disease ha3 

lasted for some time. 

Pink lenticular spots. None. 

Epistaxis in most cases. None. 

Heat of skin preternaturally great. Occasionally slight heat of skin. 

Pulse over 100 generally. Under 80 usually. 

Mean duration from 20 to 30 days. About one week. 



VI. PROGNOSIS. 

The prognosis should be always guarded, for, independently of 
typhoid fever being a very fatal disease, perforation of the intes- 
tine occurs most frequently in mild cases; this accident is almost 
necessarily mortal. The younger the subject, after fifteen, the 
stronger the chance of recovery. Beyond forty the disease is 
very serious. 

When the invasion is slow, a fatal issue is more frequent than 
when it is abrupt. A sudden remission, followed by a relapse, 
with aggravated symptoms, is, according to Dr. Chomel, inva- 
riably mortal. 

The regular prognostic value of particular symptoms may be 
gathered from the subjoined table. Those under the head of D 
are the only ones actually warranting a fatal prognosis, and even 
these occur— mostly rarely — in those who eventually recover. 



254 



TYPHOID FEVER. 



A 


B 


C 


D 


Symptoms tvhich 


Symptoms which 


Symptoms occur- 


Symptoms peculiar 


occur with the same 


occur with greater 


ring with much 


to, or with the rarest 


or about the same 


frequency, but not 


greater frequency 


exceptions peculiar 


frequency and in- 


to any notable de- 


in fatal cases. 


to, fatal cases. 


tensity in fatal cases 


gree , in fatal cases. 






and in those of re- 








covery. 








Diarrhoea. 


Involuntary dejec- 


Intestinal hemor- 


Somnolence ap- 


Gastric symptoms. 


tions. 


rhage. 


pearing the first 


Morbid states of 


Meteorism. 


Delirium appear- 


day. 


the tongue. 


Dysphagia. 


ing the first day. 


Perversion of in- 


Prostration of 


Ocular injection. 


Agitation. 


telligence exhi- 


strength. 


Marked rapidity 


Somnolence. 


bited by patient 


Epistaxis. 


of pulse. 


Spasmodic move- 


declaring him- 


Deafness. 


Irregularity or in- 


ments. 


self well, while 


Tinnitus aurium. 


termittence of 


Extreme prostra- 


in reality suffer- 


Sudamina. 


the pulse. 


tion of strength 


ing under very 


Lenticular erup- 




from the first. 


severe symp- 


tion. 




Permanent dis- 
turbance of vi- 
sion in the re- 
cumbent posi- 
tion. 

Erysipelas. 

Persistence of a 
small contracted 
pulse. 


toms. 



The mortality varies at different, periods, without any appa- 
rent cause. In Paris the deaths are about 1 in 3. In Massa- 
chusetts General Hospital, from 1822 to 1S25, there were 303 
cases of typhoid fever and 42 deaths, or about 1 in 7; in 1830, 
the deaths were 1 in 3i ; in 1831, 1 in 14i ; in 1829, 1 in 25. 
From 1832 to 1835, the number of cases was 129, and the num- 
ber of deaths 22, being a mortality of 1 in a little less than 6 ; 
while, from 1836 to 1838, the number of cases was 108, and 
the number of deaths 7, or 1 in 15. From November, 1836, to 
November, 1838, there were 55 successive cases without a single 
death; and the treatment was essentially the same during the 
whole of these periods. Jacquez, in a recent memoir reported 
on by Louis at the Academy of Medicine, states that his mortality 
was 1 in 45. 



causes. 255 



VII. CAUSES. 



1. Age. — The maximum frequency is between eighteen and 
forty. After forty the liability diminishes, and it is rarely met 
with in old persons, though there is some evidence to favour the 
opinion that it may occur even among them, especially in this 
country, more frequently than is generally believed.* 

2. Recency op Residence. — According to the French writers, 
strangers recently arrived in large towns are particularly obnox- 
ious to the disease. Nothing positive has as yet been ascertained 
on this subject in this country. 

3. Climate. — It is the endemic continued fever of the tempe- 
rate climates of Europe and this country. 

4. Contagion. — Though often arising spontaneously without 
any appreciable cause, typhoid fever is undoubtedly propagated 
by contagion. There is an accumulation of evidence on this 
point which cannot be resisted. It appears, however, certain 
that the contagion of typhoid fever is much more active in rural 
districts than in populous cities. Most of the French physicians 
practising in small towns and in the country, have long advo- 
cated the contagiousness of typhoid fever, whilst the Parisian 
physicians have, until very recently, generally denied it.t Dr. 
Nathan Smith, as far back as 1824, maintained that it was as 
contagious as small-pox or measles. The contagious principle is, 
probably, in most instances, not very active. 

* [Gendroiv mentions three cases between fifty and sixty, and four where they 
were between sixty and seventy-five. M. Jac<ujez, in a recent memoir presented 
to the French Academy of Medicine, notes several persons aged from sixty to 
seventy, and one between seventy and eighty, whom the disease had not spared. 
Petit observed the disease in a subject aged sixty; Montault in one sixty-five, 
and Andrai. in one aged seventy. Rater related to the French Academy a well- 
marked fatal case of typhoid fever in a woman aged fifty-six. A similar case, 
in a woman sixty-three years of age, is given by Dr. Bartlett. In 1837 Prus 
read to the Societe de Medecine an example in a woman aged seventy-eight] 

j- [In July, 1829, Dr. Bretonneatj transmitted to the Royal Academy of Medi- 
cine a communication, in which he asserted the contagiousness of typhoid fever, 
as it prevailed in the country .a Chomel, in his Legons de Clinique Medicale, 
published in 1834. inclined to this opinion, though, as he acknowledged, it was 
contrary to the general sentiment. Dr. Gexdroat, of Chateau-du-Loirs,6 in an 
elaborate memoir, gave a number of indisputable instances of contagion. Dr. 
Louis, in the last edition of his "Fievre Typhoide" adopts the belief, and in a 
recent session of the Academy of Medicine, this distinguished authority stated, 
that he had observed four cases in Paris, respecting which it was impossible for 
him to entertain a doubt. Contagion appeared to him to be especially manifest 
when the hospitals were over-crowded. Dr. Moreatj, of Paris, in a previous 
session, related a striking and undoubted instance of contagion. The evidence 
of Prof. Forget, of Strasburg, Dr. Leuret, of Nancy, Mistler and Ruef, of the 
department of the Lower Rhine, Putegnat, of Luneville, Jacqjjez, Patrt, &c, 
is to the same effect, and irresistible.] 

a [Archives de Medecine, vol. xxi., p. 57.] 
b [Journal des Connaissances.] 



256 



TYPHOID FEVER. 



VIII. TREATMENT. 



Typhoid Fever runs a definite course, with a natural tendency 
to a happy termination. Young and previously healthy persons 
pass through the disease favourably, with little or no treatment. 
In the celebrated Irish epidemic, which has been so often alluded 
to, the mortality amongst those patients who were placed in sheds 
on straw, and received no medical attendance, was slight; of sixty 
cases, allowed by Dr. Piedagnal to run their own course, three 
only ended fatally; of eight hundred and nineteen cases treated 
exclusively by the Homoeopathic plan, extending over a period of 
nine years, one hundred and forty died j* and of sixty-three cases, 
in which the late Dr. Williams, of St. Thomas's Hospital, Lon- 
don, used only simple enemata of warm water, all got, well but 
one. This disposition to recovery should not then be thwarted 
by meddlesome interference, or mischievous activity. There are 
no means by which an attack of typhoid fever can be cut short, 
or its duration even materially abridged. All treatment must be 
auxiliary, and should be directed towards the shelter, from seri- 
ous harm, of the essential functions. In the treatment of this 
affection " he must be reckoned the safest and best practitioner," 
says the judicious Dr. Watson, " who knows when to abstain 
from acting, as well as to act; who has learned when and to what 
extent the case may be left to the salutary processes of nature. " 

A primary consideration should be a regard to the prevalent 
epidemic constitution; for this, as has been shown, is constantly 
changing, and forbids the idea of any absolute system of treatment 
being established. Whilst in one year evacuants are necessary, 
in another they may do positive harm, stimulants being demanded 
from the beginning. The circumstances, too, under which death 
takes place, vary with different epidemics, and should be particu- 
larly noted, as the safest guide to the general principle of treat- 
ment — its great object being, in the language of Cullen, "to 
obviate the tendency to death." 

Local complications are the most frequent immediate sources 
of danger. It becomes then the object of the practitioner to 
oppose those tendencies to organic change which may be de- 
tected. Though, doubtless, often inflammatory in their nature, 
they are materially modified by the primary affection, and evacu- 
ants are. as a general rule, but ill borne in their treatment, their 
effects differing widely from those resulting from their use in idio- 
pathic inflammations of the same organs. General blood-letting, 
therefore, should be resorted to with great caution, only when the 

* [Dr. Fleischmann's Report of the Hospital of the Sisters of Charity of 
Vienna, quoted by Drs. Drysdale and Russel in Introduction to the Study of 
Homoeopathy. London, 1845.] 



TREATMENT. 257 

necessity is urgent, and during the first days. The bleeding 
should not be large, the patient being placed, during the opera- 
tion, in an upright position. The circumstances which justify a 
recourse to it, are the unequivocal evidence of local inflamma- 
tion, conjoined with a full, hard, and not very frequent pulse. 
Severe cerebral symptoms, at an early period of the disease, — 
intense pain in the head, intolerance of light or sound, violent 
delirium — conjoined with a hard, active pulse, are often relieved 
by a moderate bleeding. But it should be recollected that the 
febrile excitement at the outset is, in a large number of cases, 
speedily followed by adynamia, and is a fallacious guide for de- 
pletion. Local bleeding, by cups or leeches, is less debilitating, 
and usually quite as efficacious in alleviating cerebral, abdominal, 
or pulmonic complications. Leeches should be used with cau- 
tion, especially after the first period, and the hemorrhage stopped 
immediately upon their removal ; the writer has seen fatal ex- 
haustion occur from a neglect of this precaution. At the begin- 
ning of the attack purgatives may be given with advantage, 
unless diarrhoea should exist to any degree. 

1. Cerebral complications are to be combated by general and 
local bleeding — leeches to the temples and behind the ears, or 
cups to the back of the neck, with the precautions indicated, — the 
removal of the hair, and constant cold applications or evaporating 
lotions, and stimulating pediluvia. Sleeplessness and agitation, 
accompanied with mild delirium, frequently abate on the exhi- 
bition of opium ; but it should be administered with the greatest 
caution, and not until arterial excitement has subsided, or if there 
is any disposition to coma, (see p. 220.) When coma is profound, 
Dr. Watson recommends highly a blister to be applied to the 
shaven scalp. 

Nervous tremors, subsultus, &c, frequently yield to camphor, 
musk, opium, &c. 

2. Abdominal complications, — Pain and tenderness in the 
umbilical and coscal regions are often relieved by light warm 
poultices, rendered slightly stimulating by mustard, and by turpen- 
tine fomentations. When the pulse and urgency of these symp- 
toms warrant the abstraction of blood, leeches or cups may be 
resorted to. Moderate purging, at the beginning of an attack, is 
serviceable ; and the bowels should be kept free by laxatives or 
enemata throughout its course. If the diarrhoea is excessive, 
small doses of mercury and chalk may be given, or it may be 
necessary to resort to astringents, or even to opium, when not 
contra-indicated by the presence of cerebral symptoms. Exces- 
sive tympanitis is most effectually relieved by the exhibition of 
turpentine in small doses, or of enemata of turpentine and assa- 
foetida. Dr. Schoenlein, of Berlin, recommends, as the most. 

17 



i 



258 TYPHOID FEVER. 

effectual remedy for the relief of this symptom^ frequent enemata 
of cold water. 

3. Pulmonic complications. — When the chest symptoms are 
urgent, blood may be abstracted locally, regard being had to the 
stage of the disease, and the state of the circulation. Fomenta- 
tions of turpentine produce great relief in the congestive pneu- 
monia of the latter period; and the carbonate of ammonia enjoys 
a good deal of reputation under the same circumstances. A con- 
stant change of position is of primary importance, both in pre- 
venting and relieving the hypostatic congestion of the advanced 
stages of the disease. 

Whilst we meet the urgency of the intercurrent affections, we 
should not be unmindful of the system at large, or forget that the 
patient may perish from mere exhaustion or asthenia. The state 
of the circulation must be carefully watched, and its condition be 
our guide in the administration of stimuli. Wine, brandy, the 
carbonate of ammonia, quinine, &c, should be given after the 
first week. The evidence of their utility is to be found in an 
amelioration of the symptoms on their exhibition — by the falling 
of the pulse, and its increased force; the cessation of the delirium; 
and the improvement in the secretions; if, on the contrary, the 
febrile excitement is increased, the delirium aggravated, &c, they 
should be discontinued. As a general rule, however, their free 
exhibition is attended with benefit, and the fault usually com- 
mitted is not resorting to them sufficiently early. 

The patient should be placed under the most favourable hygi- 
enic conditions ; he should be withdrawn from the influence of 
all unfavourable or aggravating circumstances; perfect quietude 
of mind and body should be strictly enjoined ; together with free 
ventilation, light bedding, great cleanliness. The body should 
be repeatedly sponged with tepid or cold water, according to the 
feelings of the patient, to which vinegar or some aromatic spirit 
may be added. To abate the urgent thirst, felt at the beginning, 
the mildest drinks, iced and slightly acidulated, if grateful, may 
be given, in small quantities at a time. For the first three or 
four days, absolute diet should be observed ; after that period 
nourishment should be regularly given, by day and night ; the 
quantity should be small, and the intervals short. Beginning 
with the light farinaceous articles, the animal broths, milk, eggs, 
jellies, &c, may afterwards be permitted ; finally, when the pros- 
tration is extreme, the strongest beef tea is necessary. If there is 
one point in the conduct of continued fever more to be insisted on 
than another, we believe that it is the due and proper administra- 
tion of nourishment.— Frequent examination should be made of 
those parts of the body exposed to pressure; they should be sub- 
jected to gentle friction, and the air or water cushion used. 



IDENTITY OF TYPHUS AND TYPHOID FEVER. 259 

The condition of the bladder should be ascertained from time to 
time, and the water drawn off when necessary. 

During convalescence great care and vigilance are required; 
the condition of the patient should be narrowly watched, and the 
slightest return of evening feverishness should receive immediate 
attention. The diet should be regulated with extreme caution, 
relapses being not unfrequently produced by some indiscretion in 
regimen. Exposure to cold and fatigue, and mental excitement 
of any description, are to be especially avoided. 

A number of specific methods of treatment of typhoid fever 
have lately been proposed. One cures all his cases by purgatives, 
or emeto-cathartics ; another is equally successful with small 
doses of the nitrate of silver ; whilst a third lauds the extraordi- 
nary power of alum, or chlorine water. In a disorder where so 
many recover spontaneously, there are too many difficulties and 
sources of fallacy, to warrant our attributing to any exclusive 
method of treatment, the merit of effecting cures, especially 
when such a plan is repugnant to analogy or general therapeutic 
principles. 



IX. IDENTITY OF TYPHUS AND TYPHOID FEVER. 

The question of the identity of typhus and typhoid fever has 
been one of great interest, and respecting which much diversity 
of sentiment at one time prevailed. Whilst the British physicians, 
held, with great unanimity, the opinion that, though different 
varieties, they were the same species of fever ; the French and 
American authorities proclaimed their essentially dissimilar nature. 
For obvious reasons the present work is not suitable for the dis- 
cussion of this point ; and it is our intention merely to state the 
grounds on which those who contend for the non-identity of the 
two diseases base their opinions, and to ascertain how far they 
are in accordance with the observed facts. The leading features 
of difference insisted on to prove that the two varieties of fever — 
typhus and typhoid —are radically distinct, are, 1. The character 
of the eruption, which in typhoid fever consists of minute lenti- 
cular papulae, disappearing on pressure, and thinly scattered over 
the abdomen and chest ; whilst in typhus the spots " are more 
irregular in their shape and size ; not elevated above the adjacent 
skin; partially disappearing on pressure, or not at all; often 
abundant, or even confluent ; in many cases occupying the skin 
of the extremities as well as that of the entire trunk,, and usually 
of a duller and more dusky colour than in the former disease."* 
2. The infrequency of the abdominal symptoms— diarrhosa, and 
pain and gurgling on pressure in the right iliac region — in typhus^ 

* [Bartlett, loc. cit., p. 270.] 



260 TYPHOID FEVER. 

which occurs so constantly in typhoid fever ; and, 3. The absence 
in typhus of the characteristic intestinal lesions — specific alteration 
of the agminate and isolated follicles — of typhoid fever. 

Let us briefly examine how far these asserted differences are sus- 
tained by observation, assuming, for the purpose of having some 
distinctive or pathognomonic trait assigned to typhoid fever, that 
a diseased condition of the glands of Peyer is necessary to consti- 
tute the disease. 

Dr. Gaultier de Claubry* has demonstrated the complete 
identity of the camp and jail fevers of the Continent of Europe, 
with the typhoid fever of Paris, which, again, has been proved 
to be identical with the prevalent form of continued fever in the 
northern and middle sections of this country. The typhus of 
camps, hospitals, and prisons, which prevailed so constantly in 
every part of Europe, at different periods, from 1742 to 1815, was, 
as to symptomatology, march and pathology, the form of fever 
described by Louis, Chomel, Forget, &c. In the last edition of 
his work on Typhoid Fever (1841) Dr. Louis has recognized the 
perfect identity of two diseases. 

Between the first of October, 1839, and April, 1840, an epi- 
demic continued fever prevailed in the prison at Rheims, in France, 
and which has been faithfully described by Dr. LANDouzY.t 
The epidemic in question was confined to the inmates of a cer- 
tain quarter of the prison at Rheims, and prevailed between the 
1st of October, 1839, and April, 1840. The entire number of 
cases was 138, 103 of which were amongst the inmates of the 
prison ; the remaining 35 consisting of physicians, medical stu- 
dents, nurses, and others connected with the hospital where the 
patients were treated. An important point connected with these 
cases is, that they all came under the observation of the medical 
attendants immediately on the commencement of the disease. 
Among the first symptoms was stupor, which frequently showed 
itself as early as the second or third day, and continued until 
it was lost in coma or delirium. It differed from mere som- 
nolence and coma. The expression of the countenance was that 
of half-demented and stupid astonishment. It was the stupor 
attonitus of Foes. In half the cases it was strongly marked, in 
the other half it was slight in degree. True somnolence and coma 
appeared in a certain number of cases, later in the disease, often 
about the tenth day. Profound coma, so that the patient could 
not be roused, existed in only twelve cases. Delirium was very 
common, usually making its appearance between the third and 
the eighth day. It was generally low and muttering in its cha- 
racter, and, in fatal cases, it continued until death. Headache 

* [De l'ldentite du Typhus et de la Fievre Typhoide, &c. &c, Paris, 1844.] 
f [Archives Generates de Medecine, &c., Paris, 1842. Bartlett, loc. cit., p. 
302.] 



IDENTITY OF TYPHUS AND TYPHOID FEVER. 261 

was uniformly present at the commencement of the disease. It 
was, for the most part, dull and heavy, and felt especially over 
the eyes, It continued for an uncertain period of time, gradually 
disappearing or losing itself in coma or delirium. Subsultus 
tendinum was common, and strongly marked in grave cases. 
Redness of the eyes, tinnitus aurium, and deafness were present 
in a certain proportion of cases, but differed in no obvious par- 
ticulars from the same symptoms in typhoid fevers. There was 
great loss of muscular strength, from the beginning of the disease. 
In every case except the first, which was not carefully examined, 
there was an abundant cutaneous eruption, consisting of small 
spots, or ecchymoses, of a red, violet, or black colour, not elevated 
above the skin, and not disappearing on pressure. They were 
always found on the chest, often also on the abdomen, and in 
some cases they extended to the arms and legs. They commonly 
showed themselves about the fourth or fifth day, and gradually 
faded away between the tenth and the eighteenth. They were 
abundant and confluent in proportion to the gravity of the disease. 
The bodies of the sick exhaled a strong, offensive odour, resem- 
bling that of mice. In regard to the absence of appetite, to thirst, 
the state of the lips, tongue, and mouth, nothing special was 
observed, differing from what occurs in typhoid fever. Nausea 
was present at the commencement of the disease in all the cases. 
Meteorism and abdominal pains were uniformly absent. 
There was diarrhoea in the beginning of the disease in only four 
cases. In all the others there was no apparent disturbance in the 
functions of the intestinal canal. The bowels were more inclined 
to constipation than to looseness. A distinct, well-marked sibilant 
rhonchus was present in all the cases. Epistaxis occurred in 
eight cases. The temperature of the surface was uniformly ele- 
vated; the heat was dry and burning. In no instance was there 
gangrene of any part of the body. In the six autopsies which 
were performed, the intestinal lesions characteristic of typhoid 
fever were present. The elliptical plates were either thickened 
and elevated, or they were the seats of ulcerations; and the mesen- 
teric glands corresponding to them were enlarged. The spleen 
was not increased in size in any of the cases : in four it seerrted 
somewhat softened. 

On the 17th of January, 1842, an epidemic fever broke out in 
the barrack of the municipal guard of Stockholm. The corps 
had been remarkably healthy for the five previous years, and 
occupied its usual quarters, which were very damp, especially in 
winter. The men were lodged in large and spacious wards, four- 
teen feet high, in each of which forty-four persons slept, two in 
a bed. The food and clothing were of the best description. For 
two months previous to the occurrence of the epidemic, the men 
were in the habit of returning to their quarters almost drenched 



262 TYPHOID FEVEX. 

to the skin, and their wet clothes were hung up in the room in 
which they slept. The atmosphere was loaded with moisture, 
and fresh air was admitted as sparingly as possible, in order that 
an elevated temperature might be maintained. The age of the 
patients ranged from 19 to 52 : — 23 were under 25 years; 20 from 
25 to 30; 12 from 30 to 35; 6 from 35 to 40; and 3 from 40 to 
53. Of 64 persons attacked 62 recovered. The cases are divided 
into three categories. A. Cases with predominance of cerebral 
symptoms, (twenty-two cases.) B. Cases with predominance of 
abdominal symptoms, (twelve cases.) C. Mixed cases, (thirty 
cases.) The premonitory symptoms, which were seldom entirely 
wanting, were prostration, anorexia, dizziness, pains in the head 
and loins, with occasional chills and troubled sleep, during an 
average period of three days. In classes A and C epistaxis now 
and then occurred; and in B and C diarrhoea, nausea, or colic, 
was sometimes met with during the period of incubation. The 
subsequent symptoms were those of typhoid fever. In classes B 
and C there were, in nearly all, ileo-csecal pain and gurgling on 
pressure, with diarrhoea ; whilst in A there was constipation, and 
the belly was soft and free from pain ; in all the cases there was 
an eruption, consisting of reddish spots, of irregular form, and 
varying in magnitude, from a minute dot to the size of a bean, 
disappearing momentarily on pressure, more or less abundant on 
the chest and shoulders, very rarely seen on the face or abdomen, 
bright red at first, usually on the third or fourth day they gradually 
became darker, assuming frequently a bluish or violet-blue tint. 
The duration of an attack was about fifteen days. Of the two 
deaths, one took place on the fifth day, when the heart was found 
softened, the blood decomposed, the spleen broken down, (en 
bouille,) and Peyer's glands enlarged, but not ulcerated. In the 
other fatal case convalescence had commenced on the thirteenth 
day, when the patient undergoing some exposure, pneumonia 
occurred, and he died on the seventeenth day. The spleen was 
softened, with a bluish-gray colour of Peyer's glands, "with 
some of the orifices of their ducts evidently enlarged."* 

Dr. Felix Jacquot, a French army surgeon, had opportunities 
of observing epidemics of typhoid fever at Paris, Lyons, Vosges, 
Strasburg, and Metz. At Lyons, the lenticular spots, with pete- 
chiae and ecchymoses, were frequent. At Metz, sudamina were 
occasionally met with, and nothing else eruptive was seen. At 
Lyons, pulmonic complications were rare, whilst at the civic hos- 
pitals they were so common, that Dr. Dctasquier was led to 
believe that pneumonia was the anatomical character of the dis- 
ease. In one epidemic, diarrhoea was a prominent, early and 
constant symptom ; whilst in another, constipation was general.t 

* [Gaz. Med., t. xii., Nos. 15 to 26, 1845.] 

j [Gazette Medicale, t. xii., Nos. 33, 34, Paris, 1845.] 



IDENTITY OF TYPHUS AND TYPHOID FEVER. 263 

Dr. John P. Mettauer, in an excellent paper on Continued 
Fever, as it prevailed in Middle Southern Virginia, from 1816 to 
1829 inclusive — a period of thirteen years* — says, " these varieties 
of fever have prevailed at different times; that is, the Synocha, 
the Typhoid, and the Typhus. Synocha, which was only the 
more open and well-developed form of the disease, prevailed 
during dry and warm, and warm and damp seasons, and always 
as an endemico-epidemic of considerable extent. From 1816 
to 1S21, both years included, and especially during the warm 
months of those years, this was the predominant form under 
which continued fever appeared; and it was uniformly distin- 
guished by the open characters of a well-marked inflammatory 
fever in a large majority of cases, throughout its more acute 
stage. During these years, too, all classes and conditions of 
society were equally affected by the disease, and, with few ex- 
ceptions, it did not part with its peculiar open characters until 
the setting in of cold weather. Many cases of ordinary continued 
fever, or as it is often termed typhoid fever, and typhus, also 
occurred during this period, though their number was small until 
after winter set in. From 1822 to 1829, the typhoid and typhus 
varieties were the predominant fevers, but there were also many 
cases of the synocha type to be met with, both during the warm 
and cold seasons of this period ; and these fevers were almost ex- 
clusively confined to certain districts and neighbourhoods, favour- 
able to the generation of a peculiar miasm, such as is believed to 
be formed during the slow decomposition of ligneous substances. 
Typhus did not generally make its appearance until many cases 
of the typhoid affection had previously occurred in a family; but 
when it did take place, it was invariably distinguished by early 
cerebral disturbance, especially depression of the nervous ener- 
gies. The face of the country and climate of the region in which 
this fever prevailed, presented nothing calculated to lead to the 
belief that it was necessarily obnoxious to the disease. The lands 
are more or less broken and undulating ; they abound in nume- 
rous small water-courses, and creek-flats which readily overflow ; 
and many of the small streams dry up during protracted droughts. 
The climate is not more variable than is usual in middle Virginia. 
With the exception of two of the years embraced in this history, 
there was nothing very remarkable or peculiar in the seasons 
favouring the production of continued fever. 1816 was distin- 
guished by an unusually dry and cool summer. From May until 
October, there was not rain enough to wet the earth an inch, con- 
sequently nearly all of the water-courses large and small dried 
up. There were many instances of wells and springs failing en- 
tirely during this year, which had never been known to be mate- 

* [Am. Journ. Med. Sciences, July, 1843.] 



264 TYPHOID FEVER. 

rially affected by droughts before. And the summer of this 
extraordinary season was so cool as to be attended with frost 
every month. This was a year of fever, and the disease assumed 
the synocha form, distinguished by well developed, and highly 
inflammatory characters; and it prevailed most extensively, 
especially during the warm months. Towards the close of Sep- 
tember, the cases of typhoid fever, which until then had not 
been numerous, multiplied rapidly, and soon became decidedly 
the predominant form, and maintained the ascendency during the 
succeeding winter. In 1827, another exceedingly dry summer 
occurred : this year was also distinguished by the almost univer- 
sal prevalence of the synocha form of continued fever, though 
there were occasional cases of the typhoid and typhus varieties 
likewise to be met with. The summer of this year was very 
nearly as dry as that of 1816, but it was exceedingly warm. As 
autumn approached, typhoid cases increased in number, and soon 
became the predominant fevers. But after winter set in, which 
was damp and remarkably mild, genuine typhus rapidly increased, 
and continued to do so the remainder of the season, and through- 
out the next year. The years not particularized in the foregoing 
sketch, were not distinguished by anything remarkable in a me- 
teorological view, but they were years of fever; and the disease 
appeared chiefly under the typhoid and typhus forms, nearly in 
an equal proportion, though cases of synocha were often met 
with likewise. 1816 and 1827 were decidedly the sickly years 
of the period embraced in this paper ; and, as already remarked, 
the synocha was the predominant form under which the disease 
appeared. In many instances the fevers of these years could be 
satisfactorily traced to malarial sources, especially at the com- 
mencement of the sickly season. But a vast number afterwards 
were as clearly referable to idiomiasma, or something like conta- 
gion, particularly as cases of fever multiplied in families, and as 
cold weather approached, or as the rigors of winter increased. 
Numerous cases occurred after the cold weather of the winter 
season set in, with individuals residing in uninfected neighbour- 
hoods, who had assisted in nursing sick relatives ; and such per- 
sons often communicated the disease to their families and neigh- 
bours who had assisted in nursing them. The propagation of 
every form of this fever by something like contagion was estab- 
lished by indubitable evidence in many instances ; but it was not 
very communicable until it had continued in a family some time, 
more especially the synocha and typhoid varieties. The differ- 
ence in the communicability of these forms and typhus was, that 
many cases of the former, or one of long continuance became 
necessary to their propagation by the contagious agency ; while 
a solitary example of the latter in many instances was sufficient 
to communicate it. In a few instances we were induced to be- 



IDENTITY OF TYPHUS AND TYPHOID FEVER. 265 

lieve that fomites propagated these fevers, as washerwomen re- 
siding in neighbourhoods remote from the seats of the disease, 
who had received and washed the clothes of the sick, and who 
were exposed in no other manner, had regular attacks of them. 

" No age was exempted from continued fever ; infants at the 
breast, and individuals upwards of sixty years old, with every 
intermediate age, being affected. Being between the ages of 
eighteen and thirty years was that most obnoxious to this fever. 
The black population were most subject to typhus, and the de- 
pressing forms of the typhoid variety. 

" The disease was frequently superinduced by catarrhal affec- 
tions, especially during variable seasons. Measles; hooping- 
cough ; chicken-pox ; worms ; conception ; parturition ; excesses 
in eating and drinking ; surgical accidents and operations ; terror; 
passion; grief; despondency; intense study ; long fasting ; colic; 
fatigue ; and some others, at different times, also seemed to ex- 
cite the disease, but as accidental or occasional causes. 

" The anatomical characters which were displayed during our 
post-mortem examinations* were lesions of the glands of Peyer; 
of the mesentery ; spleen ; mucous membrane of the small and 
large intestines ; of the peritoneal coat of the small intestines and 
stomach; of the meninges of the brain, and especially of the 
arachnoid ; effusion of serum, or blood and serum into the ven- 
tricles of the brain ; congestion or softening of the lungs, and 
gangrene of the bladder. A dissolved state of the blood was also 
occasionally met with as a post-obit appearance, especially in fatal 
cases of typhus : in such cases the lungs were more or less dis- 
organized; and in every instance the membranes of the brain 
were greatly congested." 

An epidemic of continued fever which occurred at the Lane 
Seminary, Ohio, during the autumn of 1842, and the ensuing 
winter, has been described by Dr. Thomas Carroll, of Cincin- 
nati, in the Western Journal of Medicine and Surgery, for 1843. 
In nearly all the cases diarrhoea, meteorism, and pain and gur- 
gling in the ileo-coecal region, are mentioned as present, and yet in 
many of the fatal cases Peyer 's glands were perfectly healthy ; 
but ulcerations were frequent in the large intestines. 

In October, 1S45, the writer saw several cases of continued 
fever in the wards of the Philadelphia Hospital, in emigrants just 
arrived, in which there existed, along with the abdominal symp- 
toms of typhoid fever, — diarrhoea, and pain and gurgling on 
pressure in the right iliac region — the maculated eruption he had 
previously seen in the typhus of Dublin and London. 

From these facts — few, it must be acknowledged, yet positive 

* [" We treated more than four hundred cases from 1816 to 1829, and lost only 
twenty patients. Many of the cases were of the most unpromising description, 
perhaps a fifth,"] 



266 TYPHOID FEVER. 

as far as they go — it is evident, 1. That there is no necessary or 
constant connection between the kind of eruption, and the abdo- 
minal symptoms or lesions ; — that the lenticular eruption of the 
Paris fever, and the maculated, measly eruption of the Irish 
typhus may exist conjointly with diarrhoea, and pain and gurgling 
in the ileo-coscal region, and with enlarged or ulcerated patches 
of Peyer. And 2. That there is no constant relation between the 
abdominal symptoms— pain, gurgling, and diarrhoea— and the 
intestinal lesions, since all these symptoms may be absent, not 
only in individual cases, but in a portion, or in the whole of those 
attacked in the course of a given epidemic. 

We would inquire whether the group of symptoms known as 
typhoid fever is perfectly identical at all times and at all places; 
and further, if the essential characters of typhus are so constant 
or defined, that it can be taken as a fixed term of comparison ? 
Do not epidemics of typhoid fever differ in their prominent phe- 
nomena, constantly, from sporadic cases, as well as from each 
other ? Are there not a number of accessory circumstances, so 
subtile as to escape observation, perpetually modifying the influ- 
ence of causes on the organism? General conclusions should 
not be drawn from limited observations, or from witnessing any 
disease so generally prevalent as the one under consideration, in 
a single district, or even country, 'and during a limited period of 
time. And we cannot avoid thinking that those who regard 
these two forms of fever as distinct and separate species, are 
premature in the expression of an opinion upon a subject in 
which there are, as yet, wanting many essential elements to war- 
rant a positive judgment. 



X. TYPHOID FEVER OF CHILDREN. 

Typhoid Fever is rare in the first years of life ; it is more 
common between the ages of five and eight; and is quite fre- 
quent between nine and fourteen. Of 121 cases collected by Dr. 
Taupin, 10 were children of four years of age; but of those 
cited by other writers, the range is between eight and fourteen. 
Of 111 cases recorded by Rilliet and Barthez, 81 were boys, 
and 31 girls; and of 121 observed by Taupin, 86 were boys, and 
36 girls. 

It occurs sometimes epidemically. This has been noticed at 
the Children's Hospital at Paris, and Dr. Rilliet saw an epide- 
mic typhoid fever in a small village, near Geneva, which attacked 
children only. 

The Anatomical characters are the same as in the adult ; and 
the secondary lesions are met with in about the same proportion. 
The follicular ulcerations are, however, according to Rilliet and 



TYPHOID FEVER IN CHILDREN. 267 

Barthez, less extensive and numerous, and occur more slowly, 
and cicatrization is more rapid, and inflammation and softening 
of the mucous membrane of the large and small intestines much 
more frequent; they met with them seventeen times out of 
twenty-seven. 

The symptoms are similar to those which characterize the 
disease in the adult ; though some of the more prominent occur 
with less constancy — as the rash, catarrhal phenomena, and epis- 
taxis. Rilliet and Barthez state that the abundance of the 
eruption is in inverse proportion to the severity of the attack. The 
same authorities assert that the spleen is less frequently enlarged, 
but this is denied by Taupin. The tongue, though dry, is rarely 
cracked or fissured ; retention of urine is very rare; and so also is 
delirium, especially at the outset; and when it occurs, it is never 
violent. Vomiting, particularly at the beginning, is frequent. 

The most common complication is enteritis; whilst peritoneal 
perforation, intestinal hemorrhages, and gangrene of the integu- 
ments, are extremely rare. Otitis is not unfrequent. 

The differential diagnosis is often extremely difficult. From 
enteritis it is sometimes impossible to distinguish it; and the 
distinction between typhoid fever and meningitis is often difficult 
and impossible. 

The editor thought it better to give separately a short sketch of the form of 
continued fever most prevalent in this country, even at the risk of some repeti- 
tion. The prominent and distinctive features, both of the symptomatology and 
pathology, have alone been dwelt upon to avoid tedious reiteration, the reader 
being referred for particulars to the preceding chapter. 

Erratum.— At page 240, 5th line from top, for objective read subjective.] 



268 



CHAPTER IV. 
PLAGUE. 

The Plague, or Pestis of Cullen is a disease almost exclu- 
sively of eastern occurrence, for though it may occasionally ex- 
tend rapidly to more distant parts, yet Egypt and the neighbour- 
ing countries appear to be the proper and more frequent seats of 
its devastations. This disease has been variously denned by dif- 
ferent authors ; the most applicable definition is that offered by 
Dr. Brown: — "An exanthematous disease, the eruption consisting 
of buboes, carbuncles, and pustules, white, livid, or black, and 
generally attended with malignant and very fatal fever." {Cyc. 
Pract. Med., Art. Plague.) 



I. SYMPTOMS. 

It is a remarkable fact in the history of plague, that no very 
marked premonitory symptoms precede its attack: judging from 
the analogy of other exanthematous fevers, it might have been 
anticipated that a disease so appalling in its nature, and so fre- 
quently fatal in its consequences, would have been preceded by 
some kind of warning. This is, however, not the case ; at least 
such appears to be the impression of those who have enjoyed the 
greatest opportunities of watching the whole series of phenomena 
attending its occurrence. Sir A. B. Faulkner (Edin. Med. and 
Sarg. Jotirn., vol. x.) says, that "the suddenness with which 
plague attacks its victims is altogether incredible, persons being 
known to enjoy every appearance of good health a few minutes 
before its attack;" and Bulard, who is the most recent writer on 
the subject, says distinctly, that " plague has no premonitory 
signs." [Dublin Journ. of Med. Science, vol. xiii.) 

The first stage of the disease commences generally by a not 
very distinct rigor, attended by a sense of much weariness and 
lassitude, immediate depression of spirits, pain and weight of the 
head, with sudden attacks of giddiness and dull throbbings. The 
countenance assumes an expression of exhaustion and anxiety. 
The eyelids are half closed. The eye is downcast, dull and 
sleepy ; the mouth half open, expressive of weakness and feeble- 
ness of purpose. There is an indescribable feeling of anxiety 
about the precordia, extreme restlessness, not from this cause only, 



SYMPTOMS. 269 

but from absolute pain referred to the heart itself. This is occa- 
sionally so considerable, as to become urgent in the extreme : 
sometimes there are shuddering, nausea, and vomiting. As this 
first stage advances, the gait becomes staggering and uncertain, 
not unlike that of a drunken man. This weakness rapidly in- 
creases, until at length there is total inability of either walking or 
standing. The head sinks upon the chest, and the patient seems 
unable to raise it. The whole muscular system appears to be 
powerless and relaxed. The patient not unfrequently feels faint, 
but very rarely passes into a state of syncope. In other fevers 
this symptom usually occurs late in the disease and on the pa- 
tient's sitting up, whereas in plague this position seems less to 
produce it than the horizontal ; nor is it so soon recovered from 
in this posture as in other fevers. {Russell on the Plague, p. 89.) 
The eyes become more dull and sunk ; the complexion opaque 
and dingy; and the haggard character of the countenance is 
greatly increased, the fixed anxiety of its expressions being only 
interfered with by twitchings and convulsive movements of the 
features. The skin is hot, dry, and harsh to the feel. The pre- 
cordial pain, as well as that in the heart itself, becomes more 
intense and more circumscribed. The vomiting, which now 
usually takes place, though it is seldom of a green colour, is for 
the most part bilious ; sometimes, however, it consists merely of 
the fluids which have been taken. The tongue is swollen (a very 
marked symptom of plague), covered with a white fur, which 
towards the centre glistens like mother of pearl ; towards the tip 
and edges it is moist and clean. The pulse is accelerated, small, 
and contracted. Bulard describes it as miserably small, beating 
from* 115 to 130: sometimes, however, it is not more frequent 
than natural. The respiration becomes laborious, short, and hur- 
ried ; and although the voice is not altered, the speech is thick, 
indistinct, and faltering. Darting pains are now felt in the axilla 
and groins, as well as in other parts of the body. On examina- 
tion, these are found to be connected with swellings in the neigh- 
bourhood : should these swellings have their seat in the glandular 
system, they constitute the bubo ; should they be in the muscular 
or submucous tissue, they are the carbuncle ; both of which, when 
taken in conjunction with the other symptoms, are characteristic 
of the existence of plague. These usually present an inflamma- 
tory appearance, being, in the more favourable cases, of a bright 
red colour, and of a livid or purple in those of a more dangerous 
aspect. The bowels are confined, and not easily acted on by 
medicine. The urine is high coloured, scanty, and sometimes 
entirely suppressed. 

This first stage, which usually lasts for about twelve hours, is 
succeeded by the second, essentially one of reaction. The patient 



270 PLAGUE. 

becomes more agitated, and is incessantly changing his posture, 
in the vain hope of relieving the urgent pain that oppresses him. 
Russell {op. cit., p. 88), says, that, " when asked where the pain 
Jay, the patients either answer hastily, 6 they cannot tell/ or, with a 
fixed, wild look, exclaim < kulbi ! kulbi V (my heart, my heart !") 
Should sleep be attained, disturbing dreams render it unrefresh- 
ing. The mind is unsteady and wandering, but delirium is very 
rarely observed, the unsteadiness of the intellect, which becomes 
particularly marked during the febrile exacerbations, subsiding 
into simple confusion during the frequent intermissions that take 
place. Sometimes this state of mind alternates with coma — a 
condition which argues a severe form of the disease. The patient 
is impatient of being asked questions about himself; and even 
when the power of reply remains, which sometimes is not the 
case, refuses to answer. Besides the functional impediment in 
the speech, which has been noticed, there may be observed, as 
the disease advances, trembling of the tongue; this symptom rarely 
occurring, however, until the patient has been ill for two or 
three days. The countenance now assumes a peculiarly confused 
expression. In addition to its dull, heavy, and haggard appear- 
ance, it beeomes lively and excited. The eye still retaining its 
muddy aspect, is yet strangely mingled with an unusual lustre ; 
the pupil is very much dilated. This state of the eye continues 
independently of any remission in the symptoms. The pulse be- 
comes hard and full, but not increased in frequency ; sometimes, 
however, it is so low as to be scarcely perceptible ; at other times 
it is fluttering and intermittent. The tongue is now much increased 
m size, dry, parched, and of a yellowish colour, with a red streak 
down the centre and at its edges ; then brown, cleft, and like horn 
(Bulard) ; but it never acquires the thick fur and the black colour 
so often observable in other malignant fevers. The teeth, lips, 
and lining membrane of the nose, however, are coated with dark 
sordes resembling soot. This, as it dries, assumes the form of 
powder, and falls off. The pain in the stomach, which is intense, 
is aggravated by the occasional vomiting of a blackish-coloured 
fluid ; sometimes there is distressing nausea, which no vomiting, 
either spontaneous or artificial, appears capable of subduing. The 
state of costiveness which prevailed at the onset of the disease, is 
now superseded by a tendency to a relaxed state of the bowels ; 
the evacuations are black and offensive, though less so than in 
fevers of the typhoid character ; occasionally they are mixed with 
blood, and passed involuntarily without pain ; in other cases they 
consist almost entirely of a dark grumous fluid. Not unfrequently 
hemorrhage takes place from other mucous surfaces ; most fre- 
quently, according to Russell, from the nose and uterus. Gene- 
rally speaking, if the loss of blood be considerable, fatal results are 
the consequence, especially if it occur at the advanced period of 



SYMPTOMS. 271 

the disease. Should the hemorrhage, however, proceed from the 
nose during the first moments of reaction, there is not much cause 
of alarm. The uterus appears particularly excitable during plague, 
catamenial hemorrhage often supervening upon the other symp- 
toms. In case of pregnancy, abortion with its evil consequences 
is almost certain to occur. 

Perspirations frequently take place — a symptom which expe- 
rience proves to be of the highest importance in controlling the 
character of the disease ; in fact, of all the excretions, this seems 
to be the most important in its effects. When there is suppression 
or deficiency in this respect, the worst consequences may be anti- 
cipated ; while on the other hand, if a free and open perspiration 
supervene upon the dry hot skin, and a remission in the symp- 
toms follow, it is almost certain that the crisis has taken place. 
This favourable result usually occurs in an early period of this, 
the second stage, and is characterized by a general abatement 
of the excitement; by the pulse falling to about eighty or even 
seventy, maintaining, at the same time, a steady, open character; 
by the expression of the countenance becoming more natural, the 
eye more clear, the conjunctiva losing its injected appearance, the 
pupils being no longer dilated ; in short, by a general amelioration 
in all the symptoms, while the buboes enlarge, become more ac- 
tive, and suppurate, or the carbuncles suddenly appear with broad 
surfaces, sometimes to the extent of four or five inches. Should, 
however, the disease assume a fatal tendency, the general surface 
of the skin remains dry and harsh, while the face and hands per- 
haps are covered with a cold sweat ; the pulse becomes small, 
fluttering, and almost imperceptible ; there is constant low, mut- 
tering delirium ; the breathing is hurried and laborious ; the eye 
sunk, so that the countenance has a ghastly expression ; and the 
skin covered with petechias and vibices, though the buboes and 
carbuncles are not fairly developed. The powers of life are now 
evidently giving way, and death generally ensues without a 
struggle, though Sir A. B. Faulkner (Edin. Med. and Surg. 
Journ., vol. x.) says, that " death very rarely follows a gradual 
extinction of the powers of life ; in the greater number of cases it 
is ushered in unexpectedly by some violent delirious effort, or 
suddenly terminated in convulsions." 

Such are the usual symptoms of the more common form of the 
disease ; many variations, however, occur, but before we enter 
upon a description of these, it is necessary to make a few obser- 
vations on some of the leading symptoms of the disease. 

The bubo, which forms so prominent a feature in all histories 
of the plague, is a glandular inflammation. The glands most 
usually affected are the inguinal and the axillary ; in fact, with 



272 PLAGUE. 

the exception of the parotid, maxillary, and cervical, which are 
occasionally inflamed, the glands in other parts of the body are 
seldom implicated. The two latter, indeed, are rarely enlarged, 
unless in conjunction with the parotid gland, or there be some 
carbuncular eruption in the vicinity, so that the glandular affec- 
tion appears rather to be the result of a local irritation, favoured 
by a predisposition to glandular inflammation, than an element 
of the disease. Even under these circumstances, they scarcely 
ever pass into suppuration. The parotid is most frequently af- 
fected in children. They increase more rapidly, acquire a larger 
size, and are harder than other buboes ; at the same time they 
are more indolent, and disperse very slowly. When suppuration 
takes place it is superficial, little of the glandular structure being 
destroyed. The great size which they occasionally attain without 
suppurating, appears to produce suffocation, and in this manner to 
be the immediate cause of death. 

The first indication of the formation of a bubo is an occasional 
darting pain in the immediate region of the gland ; there are no 
external signs of its existence until some hours after, when a 
deeply-seated hard round tumour, evidently movable and painful 
on pressure, becomes perceptible. The integumental covering is 
at first in no way discoloured. As the bubo increases, which it 
may do in the course of two or three days, the acute pain assumes 
a heavy obtuse character, excepting in those of a very irritable 
disposition. The swelling becomes visible to the eye, and on ex- 
amination is found to be of an oval form, and in a great measure 
immovable. The skin, though thickened, does not show any 
signs of inflammation, until the bubo has existed eight or nine 
days ; it is then tense, painful, and discoloured. During the next 
ten days the signs of its progressing to suppuration are evident ; 
on the fifteenth or twenty-second days the tumour becomes flat- 
tened, and an external opening takes place through the discoloured 
integument, by which the matter is discharged. A slow healing 
process then ensues ; and finally on recovery, a scar is left, the 
appearance of which is never obliterated. Occasionally, however, 
the course which a bubo runs is much more rapid ; when this is 
the case a fatal termination may be anticipated. (Russel, op. cit., 
p. 115.) On the other hand they often disperse gradually, and 
are ultimately wholly absorbed. A circumstance which takes 
place, apparently very frequently, is the alternate rising and sub- 
siding of the bubo ; one day it looks prominent, another day it 
appears to have receded entirely, or at least to be much dimin- 
ished : though there can be no doubt that this is sometimes really 
the case, yet more frequently it is merely in appearance, and 
seems to depend on some change in the superficial integument, 
for, on more minute examination, the subjacent gland will be 
found unaltered. 



SYMPTOMS. 273 

Besides these, which are the true plague bubo, authors describe 
the accessory and the spurious. The accessory buboes (unlike 
the bubo whose course has just been described, and which occurs 
at the onset of the disease), do not make their appearance until after 
the disease has fully set in, the period varying from some hours 
to many days; in the latter case it is generally observed that an. 
exacerbation of fever attends their formation. The spurious bubo, 
which has been particularly described by Russell, is a small, 
hard subcutaneous swelling, rarely making its appearance before 
the third day. It occurs on nearly all parts of the body. In its 
early stage it appears to be fixed, but the superjacent skin, unless 
inflamed, can be moved over it. It is not so painful as the true 
bubo, nor does it suppurate so rapidly. The integument retains 
its natural colour until the sixth or eighth days, when the swelling 
becomes considerable and protuberant, differing in this respect 
from the carbuncle or erysipelatous phlegmon. Excepting on the 
scapulas and back, where they occasionally acquire a very large 
size, they rarely exceed that of an ordinary hen's egg. 

The carbuncle rises first as a vesicular eruption, of a roundish 
shape, and slightly protuberant. The upper surface is of an un- 
even, wrinkled, grayish appearance, and contains a dusky yellow 
or blackish fluid ; on this being discharged, the surface beneath 
has an inflamed aspect, with a dark, gangrenous spot in the cen- 
tre : this usually takes place on the third day. As the carbuncle 
advances, it becomes of a livid hue, surrounded by an angry state 
of the integuments ; its centre forms a gangrenous crust, which 
gradually extends and covers over its whole surface. In those 
cases which terminate fatally, this crust remains dry ; but if a 
favourable turn in the symptoms takes place, matter is formed 
beneath, by which it is separated and thrown off, exposing a deep 
and unmanageable ulcer. This is the more usual form of carbun- 
cle: authors have, however, described many varieties. As these 
differences involve much minute description, and are of no essen- 
tial service as regards prognosis, we shall not dwell upon them 
here, but pass on to their general history. When these eruptions 
occur, they do so generally in connection with buboes. They are 
often very numerous, usually appearing in the more advanced 
periods of the disease, but never later than the eighteenth day; 
sometimes, however, they make their appearance on the first day 
of the fever. The whole external part of the body seems liable 
to them. It has not unfrequently been observed, that, on carbun- 
cles occurring on the hand, or arm, sympathetic swellings of the 
glands of the axilla take place: this also, though more rarely, 
occurs in the glands of the nroin, when the leg or foot has been 
the seat of the carbuncular inflammation In these cases, how- 
ever, the buboes are less painful, and altogether of a different 
18 



274 PLAGUE. 

description from the primary bubo. If the carbuncle pass into a 
kindly suppuration, they subside gradually and entirely. Occa- 
sionally, during the progress of the plague, common boils occur; 
which, though at first resembling some of the varieties of carbun- 
cle, are evidently not identical. They rise suddenly to a. point, 
and pass rapidly into suppuration. 

Petechias are not very common ; they usually occur in the form 
of small, dusky red, or pale purplish spots, not unlike fleabites, 
which, as the disease progresses, acquire a livid hue. They are 
not numerous, and are situated at some distance from each other. 
They rarely appear unless at a late period of the disease, and then 
only when the symptoms assume a peculiarly low putrid charac- 
ter. The skin covering the breast and mastoid muscles is their 
more usual seat. 

Purplish spots* and streaks make their appearance sometimes 
separately, sometimes together ; authors have described the former 
under the name of maculae mcrgnas, and term the latter vibices. 
They are essentially the same eruption, only varying in shape, 
presenting in one case the character of a bruise after a blow, in 
another of a bruise after a stripe or lash. They are often not 
observable, until death has taken place ; when they make their 
appearance before, they are the forerunners of this event. Of the 
same character also are lengthened narrow streaks, of a livid or 
reddish purple colour. These lines frequently occur on the face, 
to which it gives a hideous and altered expression, so altered that 
patients, under such circumstances, can rarely be recognized by 
those most intimately acquainted with them. Besides these, 
eruptions of an evanescent character occasionally take place. 
Sometimes the integument assumes a variety of dull colours; dif- 
ferent shades of blue and red, giving to many parts of the surface 
a mottled appearance, not unlike marble. This eruption often 
vanishes suddenly, and again makes its appearance ; occasionally 
before death it assumes a more permanent character; in other 
cases it amounts merely to an erysipelatous appearance, which, 
after remaining for a short time, disappears and does not return. 

Russell has given in his history of the plague a series of tables 

* It is very difficult to determine whether these maculae or the carbuncle con- 
stituted the plague token. In the descriptions which the old authors give, they 
frequently name characters proper to both. As far as general description goes, 
we should have no hesitation in saying that the carbuncle was the true token. 
Thus they are described "as originating in little pyramidal protuberances, hav- 
ing the pestilential poison chiefly collected at their bases :" besides, they are 
spoken of as being surrounded by a blue or blackish circle, or putting out blisters. 
Yet at the same lime the chief test of the token is said to be absence of pain even 
when pierced with a needle, which certainly is not the case with the carbuncle. 
The probability is, that the eruptions generally were viewed as the tokens of 
plague. 



SYMPTOMS. 275 

deduced from 2700 observations on plague eases, which show 
the relative frequency with which these several eruptions occur. 
From these tables it appears, that of the eruptions the inguinal 
buboes are the most common, exceeding the axillary by more 
than two-thirds, and exceeding the carbuncles in a still greater 
proportion. The parotids bear but a small proportion to the 
inguinal buboes, and are chiefly incident to children and to the 
youth of either sex. Spurious buboes are comparatively very 
rare. It further appears, that the simple inguinal bubo affects the 
right groin more than the left, in the proportion of 729 to 589 ; 
and that they occurred in both groins in one-eighth of the cases. 
Axillary buboes are also rather more frequent on the right side 
than on the left, but the difference is inconsiderable. Their oc- 
currence in both sides is rare, for, in 35S cases, only nine instances 
were observed. Parotid buboes very rarely occur, unless com- 
plicated with other eruptions ; and the carbuncles still more so, 
though these latter in combination with buboes are not unfrequent. 
The spurious bubo, which does not very often make its appear- 
ance, is met with as frequently by itself as in conjunction with 
other eruptions. The most frequent complications met with are 
carbuncles with buboes. 

Bulard arranges the varieties of plague, and deduces his diag- 
nosis, from the different complications of these eruptions. He 
says, that in all cases the following diagnostic symptoms occur, 
either singly or collectively : — 

1. Knotty tumours of the lymphatics in the groins and axilla?, 
rarely in the neck, and still more rarely about the knee. 

2. Petechias in the thorax, the neck, and sometimes over the 
whole surface of the body, rarely on the limbs. 

3. Carbuncles in greatest number upon the limbs, but seldom 
upon their extremities, or upon the face, or trunk of the body. 

During the prevalence of plague in 1834 at Cairo, and particu- 
larly at Smyrna, he states that these three morbid appearances 
have constantly indicated three different forms of disease : — The 
simple, where buboes alone occur ; that in which buboes and 
petechias occur together; and that in which buboes and carbuncles 
are united. He has never observed the last two forms occurring 
together ; that is, he has not met with cases in which there were 
at the same time buboes, carbuncles, and petechias conjoined. 

We shall conclude this short description of the peculiar symp- 
toms of the plague by a few observations on the state of the blood. 
This fluid, on being drawn from a vein, flows easily and in a 
continued stream. In the Trait e de la Peste it is, however, 
described as a viscid semi-fluid substance, not springing out like 
healthy blood, but trickling slowly like muddy wine-lees or even 



276 PLAGUE. 

treacle. In no stage does it ever exhibit the buffy coat ; nor, 
according to recent observers, is it ever of greater consistence than 
in health. It has a peculiar odour, and is of a dark red colour, 
which never changes, as is otherwise the case, into a bright red ; 
on the contrary, after standing for a time, the general mass as- 
sumes the tint of a violet red, becomes cupped, and has a red- 
coloured serum floating in its concavity. Sometimes, however, 
it shows no disposition to form a coagulum, but remains quite 
fluid, of a livid colour, exhaling a strong odour, which appears to 
proceed from drops of an oily-looking fluid floating upon its sur- 
face. On analysis this blood has been found to contain in 100 
parts the following ingredients : — 

f Water - 35-576 

« • j I Fibrin -624 

oagu urn, < Colouring matter, with some fibrin, albumen, 

( and fatty matter - 3-800 

[Water 54-420 

J Albumen and colouring matter - - 4-704 

~ J Extractive matter - - - - -252 

fcerum, ] Chloride of potassium and sodium - - -408 

| Carbonate, of soda and fatty matters - -216 

[ Sulphurous acid traces. 

After death the blood is found in the arteries in small quantities; 
it is as black as in the veins, fluid, and seemingly decomposed. In 
the large venous passages there is often found floating in it the 
oily looking substance, which is discharged with it during life. 



II. VARIETIES. 



Having now given a general outline of the more prominent and 
characteristic features of plague, we shall take a short review of 
the different forms in which this disease is found to occur. For 
the sake of brevity these may be referred to one of three divisions. 
1. Simple or glandular plague; 2. Eruptive plague, attended 
by a period of reaction. 3. Malignant plague, in which the 
period of reaction is either entirely absent, or but very imperfectly 
developed. 

1. The simple ox glandular form of plague is rarely fatal in its 
termination, and but seldom characterized by any very urgent 
symptoms. Sometimes, indeed, it is so slight an affection, that 
only very modera e, or even no febrile symptoms are developed. 
The patient may feel himself slightly indisposed for two or three 
days, but not to such an extent as to render confinement to bed, 
or even to the house, necessary. He is enabled to perform his 
ordinary oocupations unembarrassed by the very slight mental 
excitement and other symptoms that may be present. The 



VARIETIES. 277 

buboes, which are almost the only decisive evidence of the exist- 
ence of plague, go on kindly and speedily to suppuration. Per- 
sons thus affected are often known to walk about and pursue 
their accustomed avocations apparently in good health, and with- 
out expressing any inconvenience from the buboes. 

In other cases there is evidently a febrile excitement, which, 
though sufficiently well-marked, is neither of long duration, nor 
very urgent. For the first two or three days there are general 
nausea, loss of appetite, disinclination and some inability to use 
exertion; the skin is dry and hot, especially at night, with restless- 
ness and some degree of excitement, which scarcely ever amounts 
to delirium. The pulse is accelerated, full, and bounding; there 
is urgent thirst ; the eye, though bright, has not the singular glis- 
tening appearance that has been alluded to ; nor has the counte- 
nance the bloated drunken character so generally seen in the 
severer forms of plague. After these febrile symptoms have 
continued for a few days, they subside upon a perspiration taking 
place ; but, towards the evening of the day on which this may 
have occurred, they are renewed, to be again relieved by another 
perspiration towards morning. These nocturnal exacerbations 
and morning remissions often continue for a week, or even for 
fourteen days, before recovery may be said to be established. 
During this period the buboes pass through their several stages 
in a regular steady manner ; they are attended with rather more 
pain than when the febrile symptoms are not so marked ; if situ- 
ated in the inguinal region, as they most generally are, they may 
from their locality so inconvenience the patient, as to prevent his 
walking, when such inconvenience would not be the consequence 
of the constitutional derangement simply. Occasionally, though 
not very frequently, carbuncles occur in the slighter form ; they, 
however, quickly crust over, the crust soon separating by the 
kindly secretion of pus, the result of a healing process, which is 
quickly followed by the wound becoming sound. 

2. The eruptive form of plague, attended by a period of reac- 
tion, is of more frequent occurrence than any of the other varie- 
ties. It includes, in fact, by far the greater proportion of cases 
that occur. Their ordinary history is, a febrile paroxysm at 
night of some severity, followed by a morning remission, which 
is preceded by a state of diaphoresis more or less marked. To- 
wards mid-day an accession of febrile symptoms recurs, though 
not so intense as those of the previous night ; these are again fol- 
lowed by a remission, which is likewise superseded by the more 
severe nocturnal paroxysm. This variety of plague is particu- 
larly distinguished from the other two, by the pulse being fuller ; 
a character which it maintains in the early stage of the disease, 
and by the power of reaction when any unusual severity in the 



278 



PLAGUE. 



form of the disease may have particularly depressed the system 
— a state which not unfrequently occurs at the commencement of 
the nocturnal exacerbation * in fact, ail the symptoms point out, 
that this form is more inflammatory than the simple or glandular, 
and that the system is endued with greater power of resisting the 
malignant effects of the plague poison than the adynamic variety. 
It is also characterized by a tendency to critical perspirations on 
the third, fifth, seventh, or subsequent odd days. 

The series of symptoms attending this form of plague may be 
stated to be as follows : — It commences in a well-marked though 
by no means severe feverish attack ; there is some degree of 
restlessness, and an excited pulse, nausea and vomiting of bilious 
matter, with most probably the appearance of one or two buboes, 
and perhaps of carbuncle, of which there is often a succession as 
the disease progresses. Though the mind may, at the onset, be a 
little agitated, there is never delirium or coma. The symptoms 
sometimes assume a slight degree of intensity ; but it is very re- 
markable, that whatever be their character, whether more or less 
severe, no judgment can be formed as to the future course of the 
disease ; it is often found that the severest symptoms have super- 
vened when the commencement has been mild ; and at other 
times, when this first stage has been peculiarly violent, a mild 
form of plague has succeeded. 

On the subsequent, that is, the second day, a remission in the 
symptoms usually takes place, sometimes attended by diaphoresis. 
The heat of the surface is moderated, the pulse abates in fre- 
quency and force, but does not acquire a character which can be 
called small. There is not, however, a perfect remission, much 
headache, pain in the buboes, and nausea, being felt ; there is 
very rarely vomiting, for though this is a symptom which is 
pretty constant on the first day of attack, it rarely recurs 
afterwards. As the day advances, a return of the fever takes 
place ; it is not, however, preceded by any rigor, nor indeed 
by the least sensation of chilliness. It is, in truth, scarcely 
to be called a paroxysm, but rather an increase of the febrile 
condition which prevails during the remission. The pulse rises, 
but remains soft ; the heat of surface is moderate ; the thirst 
urgent; the tongue moist; there is much restlessness, and the 
functions of the brain are evidently affected, shown by confusion 
of intellect or disposition to coma. Towards evening a partial 
perspiration breaks out, after which these symptoms abate con- 
siderably, the patient complaining of more general indisposition, 
anxiety about the praecordia, and feeling of oppression than 
during the morning remission. As night advances the true 
febrile paroxysm ensues: the patient becomes very restless, suf- 
fers from a sensation of intense heat, the skin being perceptible 
to the touch of a high temperature; the pulse is quick and 



VARIETIES. 279 

feeble ; the eye muddy, and the countenance generally acquires 
the drunken expression so remarkable in plague ; and, in addition 
to a state of the most distressing bodily weakness, there is tran- 
sient incoherence alternating with coma. 

As the morning of the third day advances, in the more favour- 
able cases a profuse perspiration ensues, which is often critical, 
being followed by a marked remission, and immediate relief 
of the symptoms; the pulse becomes open, soft, and less frequent; 
the restlessness and thirst diminish; the intellect is more clear; 
and altogether there is a decided amendment. Towards mid-day 
there is slight febrile exacerbation, which, though somewhat 
severe, is by no means protracted, for after a very short time, a 
remission takes place ; this continues till nightfall, when another 
exacerbation ensues, characterized by a greater power of resist- 
ance in the system than during the exacerbation of the previous 
night ; the pulse is stronger and fuller, while the coma and wan- 
dering delirium abate. On the following morning (that is, the 
morning of the fourth day), the perspiration is not so copious, 
nor attended by so complete a remission as on the previous day ; 
it does not, in fact, in any way come under the denomination of 
a critical sweat. 

The exacerbation which takes place towards the middle of 
the day is moderate, while that which comes on at night is 
very severe, more so by far than the exacerbation of the pre- 
vious night/ On the morning of the fifth day another critical 
sweat breaks out ; this is the commencement of a very decided 
remission, which is followed by an exacerbation in every respect 
milder than any that have preceded it There is now evidently 
an abatement of the symptoms, and though they may continue 
somewhat in this order for a week longer, yet they daily decrease 
in intensity, so that, after the second week, their force has so far 
subsided that the patient may be declared to be in a state of con- 
valescence. During this time the buboes run a steady course to 
suppuration, and the carbuncles form very early a crust, which 
is soon removed by the healthy granulations that ensue. 

Such is a history of the more favourable cases of this form of 
plague. In those where the symptoms assume a more severe 
character, it is found that, on the third and fifth days, the critical 
perspirations either do not take place at all, or are but very im- 
perfectly marked. Instead of the symptoms remitting, or the 
system showing powers of resistance adequate to repel the nox- 
ious influence of the disease, a more alarming state of things 
comes on, and the eruption of vibices and petechiae is superadded 
to the buboes and carbuncles. As a general rule it may be said 
that, when buboes and carbuncles alone are present, a favourable 
termination may be anticipated ; when buboes and petechiae 
occur together, the result is generally unfavourable, especially if 



280 PLAGUE. 

there be superadded diarrhoea, hemorrhages, and loss of speech. 
It is, however, a very capricious disease ; occasionally the most 
urgent symptoms, to all appearances, are followed by a favoura- 
ble termination ; while at other times, apparently the mildest 
cases are suddenly cut short by death. Not above one half of 
those affected with this form of plague recover. 

We have previously alluded to the frequency of menorrhagia 
in plague, as well as to the fact that when pregnancy exists, 
abortion almost invariably takes place. Russell makes the very 
curious remark, that women, under these circumstances, generally 
die on the seventh day. He says, that he once met with an in- 
stance of a pregnant woman dying on the third day, but in gene- 
ral the seventh was the fatal period ; some very rarely struggled 
on till the eleventh. 

It may not be inapposite here briefly to sum up the character- 
istics of the two forms of this our second division of the disease. 

The slighter has more the character of ordinary fever ; the 
shivering and succeeding reaction are more marked, and the 
stomach is disordered to vomiting: — this condition, unattended 
with anything like coma, remains during the illness, the fever 
throughout the whole time never ceasing, though not unfrequently 
remitting. The buboes and carbuncles generally make their ap- 
pearance on the first day and pass on kindly through their va- 
rious stages. Generally speaking, the third morning is critical : 
if a remission of the general febrile symptoms ensue, with free 
perspiration, a favourable termination may be expected; if, how- 
ever, this should not be the case, but the skin hot and dry, with 
drowsiness, low muttering delirium, quick, small pulse, muddy 
glistening eye, and considerable jactitation, danger is to be anti- 
cipated : this condition, however, may continue for a fortnight 
before the patient sinks. 

The severer form, which is much more fatal, begins generally 
with a slight shivering and sense of cold, and is soon succeeded 
by the usual symptoms of fever, accompanied by vomiting and 
purging. The fever increasing towards night, the face becomes 
Hushed, the eyes glisten, and the patient is either delirious, or 
more or less comatose. During the succeeding days, at every 
exacerbation, these symptoms increase; the pulse becomes rapid 
and more or less full ; the eyes have the peculiar and characteristic 
muddy appearance ; there is a confused expression of counte- 
nance, with pain, heat, and oppression about the praecordia. 
From three to six days is the period in which these symptoms 
run their course. The buboes do not in general make their ap- 
pearance until the second day, and but rarely suppurate ; expe- 
rience has shown, however, that they do not influence the termi- 
nation of this form of plague, for, even if they do suppurate, few 
so affected recover. 



VARIETIES. 281 

3. The third and last division of plague, which may be denomi- 
nated the malignant, and in which the period of reaction is 
either entirely absent or but very imperfectly developed, usually 
sets in with chilliness, vomiting, sudden loss of strength, head- 
ache, confusion of ideas, giddiness, and oppression of spirits ; death 
sometimes takes place rapidly, occasionally within the short space 
of twenty hours, and even before decided characters of dangerous 
illness are apparent; for, if the febrile symptoms are but slightly 
developed, the disease may be considered to have assumed its 
worst character. In this rapid form, death ensues before buboes 
or carbuncles appear. In other cases there are, for a few hours, 
some symptoms of reaction, and signs of more general disorder 
become evident. This usually occurs towards night. The eyes 
lose their lustre, become muddy, staring, and excited ; the expres- 
sion of the countenance is haggard ; in some, immediately before 
the accession of the more violent symptoms, it assumes an ap- 
pearance of despair and horror, which baffles all description, but 
can never be mistaken by those who have once seen it ; much 
distress is felt not only in the cardiac and precordial regions, but 
Hi the heart itself, which is much aggravated by the vomiting that 
is often constant; the thirst is urgent, but the tongue is moist. 
The pulse, though often natural, is for the most part soft and 
quick, though it occasionally acquires some degree of strength 
and fullness ; this, however, is very rare. The skin remains cold, 
or if it acquire any increase of temperature, it is but for a short 
time, flushings of heat passing partially over the surface; the 
power of utterance is lost or very much impaired ; the patient is 
generally in a low, drowsy, lethargic state, but conscious, when 
roused, though there is a disinclination to be disturbed. Occa- 
sionally this state is disturbed by transient fits of delirium. It is 
in fact, sufficiently evident, that the brain and nervous system are 
seriously affected. Towards morning the symptoms abate, and 
the unsteadiness of mind is greatly recovered from ; at any rate, 
in the majority of cases, attacks of delirium no longer occur. 
Russell says, that when patients had been delirious in the night, 
they usually recovered their senses in the morning, though some- 
times disposed to ramble a little and talk incoherently, and did not 
lose them again in the subsequent exacerbations through the day. 
This comparative abatement in the severity of the symptoms 
which takes place during the day, scarcely deserves the name of 
a remission, so frequently is it disturbed by slight increase in the 
febrile tendency. Amid these very perceptible exacerbations, 
there does not appear to be left in the system stamina adequate 
to overcome the depressed state of the vital powers. The surface 
continues low in temperature ; the pulse small, equal, and quick, 
occasionally fluttering; the speech falters ; the tongue is white and 
moist; and the thirst has abated. Towards night, however, the 



282 



PLAGUE. 



symptoms become much more alarming, and are altogether indi- 
cative of an oppressed condition ; the eyes again become muddy; 
the countenance is bloated and swollen ; the anguish at the heart 
and epigastrium increases; and the restlessness is incessant; the 
pulse is small, quick, and unsteady; the thirst urgent ; the tongue 
dry; the articulation very indistinct ; delirium, or in the worst 
cases coma, comes on ; and occasionally there is vomiting, or 
purging, or both, either of which adds much to the general distress 
and hastens the termination of the disease. Towards morning a 
calm ensues, which is occasionally accompanied by perspiration. 
Those who are not accustomed to this form of the disease, are 
very apt to argue favourably from this event. It is, however, 
entirely fallacious. The quiet condition in which the patient lies 
is rather attributable to exhaustion from the excessive restlessness 
and febrile state of the previous night, than to any real abatement 
of the disease. During the day many exacerbations of febrile 
action take place; but these are so slight and so little marked from 
the weak and sinking state in which the patient is, that, without 
the minutest observation, their presence might not be perceived. 
Towards night death often takes place, though occasionally the pa- 
tient survives in a low typhoid delirious condition, in which there 
are much drowsiness and alarming prostration, the body being 
covered by petechias and vibices, while buboes and other cha- 
racteristics common to putrid disease, but very rarely carbuncles, 
make their appearance. When buboes are present they are not 
usually observable before the second day, generally on the third, 
are attended by little pain, and never pass into suppuration. The 
course of this form of plague is not apparently influenced by the 
appearance, or by the progress of the buboes. When carbuncles 
occur, which, as we observed, is very rarely the case, crusts form 
round the edges, of which a little matter is secreted, but never to 
such an extent as to facilitate the separation of the crusts ; some- 
times they remain dry and shriveled. Very few, indeed, it may 
be said none, of those who are attacked by this form of plague 
recover. They usually die, as is observed in the severer cases, on 
the first or third days, and but rarely survive the fifth. 



III. SEQUELAE AND COMPLICATIONS. 

The consequences of plague are not very numerous. The 
period to which the fatal termination is postponed, varies accord- 
ing to the nature of the disease and the constitution of the patient. 
Occasionally, when the specific influence which causes plague is 
in its greatest intensity, the system yields to it, and sinks without 
a struggle, a few hours only intervening after the first symptoms 
have appeared. These rapid and malignant cases are usually 



ANATOMICAL CHARACTERS. 283 

met with at the very commencement of the epidemic; afterwards 
cases are frequent in which the patient lingers till the seventeenth 
or twentieth day. Death ensues, sometimes as the result, as it 
were, of pure exhaustion; sometimes as the consequence of syn- 
cope ; at other times it occurs from a convulsion, or a sort of 
apoplectic seizure. When recovery takes place, the convalescence 
which immediately follows on the cessation of the more severe 
symptoms, though not very protracted, is yet generally attended 
by a slight febncula ; this, in fact, continues until the complete 
healing of the buboes has taken place, when there remain scars 
which are never obliterated. 

A very curious consequence of recovery from plague, which 
has been much dwelt on by some writers, is a tendency to lewd- 
ness and incontinence. The degree of frenzy and bestiality 
which has attended this disposition has, in some instances, been 
excessive : with the exception of these, authors have not particu- 
larly mentioned any very marked local or functional disorders as 
sequelee of plague ; nor do they mention that it is complicated 
with, or modified by, other diseases. We may therefore con- 
clude, either that they do not take place, or, if they do, that the 
symptoms of plague are so prominent as to obscure them. Al- 
though these complications are not spoken of, yet many observers 
state the very remarkable fact, that open wounds apparently 
afford protection against an attack of plague. As early as the 
time of Galen the observation was made, that, while the disease 
was raging on all sides, those having running issues were not 
affected. The same fact has been observed by many modern 
writers; Desgennetes observes, that "wounded men enjoyed 
an immunity so long as their wounds were in a state of excessive 
suppuration, but which they lost when their sores healed." Some 
of the older writers, with Sydenham and Heberden, mention 
plague as preceded by, and in the first instances complicated with, 
a very fatal form of spotted fever. — There can be no doubt, from 
the light thrown on this subject by the more extensive observa- 
tions of some modern writers, that these were really cases of 
plague, but not characterized by the formation of the bubo. 



IV. ANATOMICAL CHARACTERS. 

Until within the last few years the knowledge of the lesions 
which take place in plague was very limited ; for not only was 
there an overwhelming feeling of the danger of such examina- 
tions, but the prejudices of the countries in which this disease 
most usually occurs were opposed, under any circumstances, to 
such investigations. In more recent times, however, these feel- 
ings and difficulties have been overcome : and the researches 



284 



PLAGUE. 



which have been made by Frank, Chicoyneau, Verny, Fonil- 
lier, Deidier, and more especially Bulard and Clot Bey, 
furnish us with very extensive details of the morbid states ob- 
servable after death. Before describing these, however, it must 
be borne in mind, that no very great extent of morbid lesion is to 
be seen in the most malignant forms, but rather in those where 
the disease has been protracted. It may, in fact, be stated, that 
the number and intensity of the organic changes observable, are 
in an inverse ratio to the intensity of the disease. With this ex- 
planation we shall now proceed to state the appearances which 
have been noticed on dissection. 

Externally on the neck and upper part of the chest, on the 
limbs and about the external organs of generation, distinct pete- 
chias, large vibices, and extensive masses of discoloured integu- 
ment, are in most instances observed. These appearances have 
generally been assumed as indicative of a very putrid state of the 
body ; but there is really in the bodies of those dying of plague, 
no particular tendency to rapid decomposition. Besides the erup- 
tions now described, there are usually many carbuncles in different 
stages and forms scattered over the person, together with buboes 
in the groins and arm-pits, and occasionally, though very rarely, 
in the neck. According to Clot Bey, wherever buboes had not 
made their appearance, the lymphatic glands generally were en- 
larged. The subcutaneous veins are not distended to an extent 
to be externally apparent. The expression of the countenance is 
sunken and collapsed, having entirely lost the bloated and livid 
aspect which it presented shortly before death. The eyelids are 
closed, the mouth is open and covered, as well as the nose, with 
sordes, and the dark-coloured matter which has been vomited. 
There is a general impression, that the countenances of those 
dying of plague are peculiarly deformed; but this does not really 
appear to be the case ; indeed, Clot Bey says decidedly, that 
" the corpses have not the hideous aspect which physicians have 
described, and artists painted." 

The muscles never acquire that perfect rigidity which is usually 
consequent on death. Their softness and want of cohesion in the 
fibre evidently show that a considerable deficiency of tone had 
taken place throughout the whole muscular tissue during the pro- 
gress of the disease. In colour they appeared to be somewhat 
livid, presenting here and there characters of a more localized 
inflammation. 

In the cavity of the cranium, with the exception of some little 
fullness of the vessels, no very particular morbid appearances 
have been observed. The brain itself, in some few cases, may be 
said to be generally softer than is usual, and there may be rather 
an injected appearance in its medullary portion, as well as a 



/ 



ANATOMICAL CHARACTERS. 285 

lighter colour than natural of its cineritious substance. The ' 
sinuses of the dura mater, together with its vessels, are certainly 
distended, but the dura mater itself, and the other investing mem- 
branes of the brain, show no signs whatever of inflammation, nor 
is there otherwise any trace of disease in them. The choroid 
plexus is not unduly injected, nor is there any morbid increase of 
fluid in the ventricles. Bulard says, that " the sympathetic . 
nerve is neither red nor softened; its ganglia are always healthy; 
and it is only in some rare cases that petechiae, or rather an exu- 
dation of blood, have been seen on it in the lower part of the 
chest ; when closely examined, these specks are found to be only 
of the thickness of the neurilemma, and do not pervade the tissue 
of the nerve." The neurilemma also undergoes a remarkable 
change in size, where the nerves are included in knotty swellings 
of the lymphatics. When these swellings are much developed, 
and when there is much blood in the part, then the outer surface 
of the neurilemma is observed to be freely covered with these 
specks; but on a slight incision, and a careful dissection being 
made, it may easily be seen that they are confined to the external 
layer of the neurilemma and to the cellular tissue surrounding it. 
The different plexuses of nerves, and particularly the solar, are 
without any appreciable alteration. 

The diaphragm has, in one or two instances, been found in- 
flamed, and to have petechiae scattered over its surface. Generally 
speaking, the state of the lungs presents nothing unusual ; some- 
times they are slightly engorged ; and cases are mentioned, where 
an inflammatory appearance has been observed. Dr. Craigie, 
however, describes the lungs to be of a deep black or livid colour, 
with their vessels distended by a thick dark-coloured blood, and 
their substances softened, in some instances chequered by livid 
stripes or patches, generally swelled or enlarged, so as to protrude 
the heart and project occasionally from the chest. The changes 
in the circulating system are extensive and important. The peri- 
cardium rarely presents externally any particularly diseased ap- 
pearance, with the exception of its being distended. Internally, 
both where it is free and where it covers the heart, petechiae in 
distinct spots are occasionally met with ; usually its cavity contains 
rather a larger quantity of fluid than is natural. This fluid is of 
a -bloody colour — a fact which Baron Larrey, in his Memoirs 
of Military Surgery, particularly dwells on. The heart itself is 
almost invariably found flabby and enlarged ; it is said to be 
generally one-third larger, and Clot Bey even speaks of its being 
twice the natural size ; its fibre is pale and softened. The system 
connected with the venous circulation appears to be especially 
disordered. The orifice of the right ventricle is usually dilated, 
as well as the ventricle itself, which contains a quantity of black 



\ 



286 PLAGUE. 

fluid blood surrounding a mass of fibrin. The whole system 
appears overloaded and distended, at least this is evidently the 
condition of the venae portas and larger veins, which are in many 
places discoloured and obviously diseased. The blood which 
they contain is fibrinous, and of a dark colour, with oily-looking 
particles, resembling greasy soup, floating on its surface. Occa- 
sionally it has been observed to be unduly liquid, inflammatory, 
and sizy. [Relation Historique de la Pesle de Marseille.) The 
arteries are for the most part empty, and to all appearances 
healthy, excepting in some rare cases where a few livid spots are 
scattered over their external coat. These are not of so defined 
and decided a character as to warrant their being termed pete- 
chias, though doubtless they are of the same origin and character. 
The digestive organs, in many respects, show evidence of very 
considerable disease. There is almost always general softening 
of the membranes, which compose the alimentary canal ; the 
serous muscular, or mucous membranes of which appear to be so 
degenerated in their structure, that they are torn with the slightest 
force. The stomach internally is covered over with slimy yellow- 
ish mucus, (Savaresi, Histoire Medicate de PJlrmee d* Orient,) 
and contains a quantity of a dark-coloured fluid; at times this 
fluid is almost black, and, on analysis, (Wochenschrift fur die 
gesammte Heilkunde, No. xlii.,) has yielded in 100 parts — 

Water ------ 95.75 

Oxide of iron ----- -25 

Resin ------ 1-75 

Mucus and fat - - - - -25 

Albumen with colouring matter - - - 2-00 

The authors of the Relation Historique de la Peste de Mar- 
seille, state, that in many of those who died during the pestilence 
which raged there in 1720, the bodies which they examined pre- 
sented no particular appearances of disease, with the exception of 
slight traces of inflammation perceptible in the mucous membrane 
of the intestines. Recent investigation has, however, shown, that 
on washing away the slimy yellow mucus from the stomach, its 
mucous surface is covered in many places with very distinct pete- 
chia, varying according to Bulard, as in the skin, in colour and 
size. They sometimes run together, so as to form a continuous 
bluish-red surface, of a very characteristic appearance, and which 
can in no way be confounded with the appearances of the inflam- 
matory stage of acute gastro-enteritis. Occasionally, in some very 
protracted cases, ulcerations are observable among the rugae ; 
seldom, however, towards the cardiac orifice. These ulcerations 
generally appear across the lines of the rugae, sometimes they are 
situated longitudinally in the folds. They never appear to be 
very deep, or to affect any other than the mucous membrane. 
The appearances that these ulcerations present are, small defined 



ANATOMICAL CHARACTERS. 287 

circles of a reddish liver colour, surrounding an abraded surface, 
in the centre of which is seen a small dark spot, evidently gan- 
grenous. 

The small intestines are generally distended. Externally, with 
the exception of the softening of their coats and a slight yellowish 
tinge, there are no evidences of alteration of structure. Internally, 
there is frequently a small quantity of a dark-coloured fluid, not 
dissimilar to that found in the stomach, the mucous surface being 
covered with numerous petechias, smaller and more distant than 
those in the stomach, and here and there are extended spots of 
one or two inches in length, of a red colour, as well as streaks 
resembling ecchymosis. The ilio-ceecal valve and the appendix 
vermiform is are often discoloured and of a livid hue. The latter 
is sometimes very much enlarged, even in some cases to three 
times its usual size. The large intestines are rarely diseased. 
The liver is perfectly natural as far as regards shape and size ; 
sometimes, however, a few petechias may be met with upon its 
external surface, and occasionally, but the cases are very rare, the 
border of the left lobe is occupied by carbuncular inflammation. 
On cutting into its substance, it is found gorged with blood, but 
not to any greater extent than might have been expected from 
the loaded state of the venae portas and the venous system gene- 
rally. The gall-bladder, to all appearances, is distended, and its 
sides are thickened, and have somewhat of a bluish tinge. The 
quantity of bile which it contains is, nevertheless, not very con- 
siderable ; it is of the ordinary dark-greenish colour, and of the 
usual consistence ; sometimes, according to Larrey, (Memoirs of 
Military Su? % ge7y,) it is very fetid. Diedier (Dissertation sur 
la Contagion de la Peste) says, that " in many of those who died 
at Marseilles, during the time that the plague raged there in 1720, 
the gall-biadder was found to be extremely loaded with black or 
greenish bile." Of all the viscera the spleen is the most frequently 
altered in structure : it is frequently considerably enlarged. Its 
external covering is usually softened and covered with petechias : 
internally its parenchyma is broken down, presenting the appear- 
ance of grumous blood. 

The pancreas has been found in some few cases slightly hard- 
ened and enlarged, but this lesion is so rarely observed, that it can 
scarcely be said to be proper to plague. The kidneys are usually 
increased in bulk, varying from the least perceptible increase to 
three times their ordinary size. Their external surface is not un- 
frequently spotted with petechias, which from running together, 
give the appearance of ecchymosis. The structure of the interior 
of the kidney is not materially altered, excepting that it is softer 
and more easily torn. It is overcharged both in its cortical and 
tubular structure with a black fluid blood. Clot Bey describes 



288 PLAGUE. 

it as of a deep violet colour, gorged with blood, and to have a 
true hemorrhage into the pelvis. The ureter also partakes some- 
what of disease, for, generally speaking, extensive ecchymoses 
are found to have taken place beneath its external coat. The 
bladder is but very rarely affected, but is generally found to con- 
tain a quantity of urine, deeply tinged with blood. In very 
severe and protracted cases, however, its mucous membrane may 
be covered with patches of mucus, and occasionally spotted with 
petechias. 

When the glands (chiefly the inguinal and axillary) are dis- 
eased, they are enlarged, and covered with bruised-like integu- 
ment. On cutting into them there is much sanguineous effusion 
in their immediate neighbourhood ; and surrounding and con- 
nected with them are knotted masses of lymphatic tissue, as well 
as portions of cellular membrane, the inflammation and enlarge- 
ment of which form small tumours. The diseased glands are 
found varying from their natural size to that of a large egg, rang- 
ing in colour from a gray to the deepest livid, and in point of hard- 
ness from that of a scirrhus to fluid softness. When cut into, this 
is immediately explained, by their presenting every condition 
from the earliest stage of inflammation to that of suppuration. 
Clot Bey {Brit, and For. Med. Rev., vol. i. p. 24S), says, that 
"the lymphatic glands are always gorged, sometimes increased 
five or six times, softened, and of a colour like lees of wine, and 
sometimes black ; those of the groin or arm-pit, by their agglome- 
ration, form a homogeneous mass, of a colour almost always like 
lees of wine, with effusion of black blood into the surrounding 
cellular tissue. A similar change may be seen in the chain of 
glands along the vessels of the abdomen and chest; and in many 
cases the extravasation of blood around them amounts to hemor- 
rhage.'' 

Such may be considered as the more ordinary lesions which 
take place in plague. The last that have been now described, 
namely, those of the lymphatic system, Bulard views as pri- 
mary, they being the essential lesions of the disease ; while he 
regards the others as secondary, and the consequence of diseased 
actions originating in the primary lymphatic affection. 



v. DIAGNOSIS. 

A few words only need be said on the diagnosis of plague. 
This disease, for the most part, is not likely to be confounded with 
any other. Its symptoms are usually so well marked, that in 
those cases which run a complete course, no hesitation need be 
felt in deciding on its identity. The intense fever, the staggering 
gait, and the eruption of the buboes, &c, sufficiently indicate its 



PROGNOSIS. 289 

presence. Under two conditions, however, some little difficulty- 
may occur. The first is to distinguish it from a low typhoid fever, 
when the eruptive symptoms have not shown themselves; and, 
in the other case, it may be mistaken for syphilis when inguinal 
bubo without concomitant fever appears. 

In the former case the peculiar expression of the eyes, the en- 
larged tongue, and the difficult articulation, are indications suffi- 
ciently distinct of its being the true plague; while, in the latter, 
the lower situation in the thigh of the glandular swelling than is 
usual in syphilitic irritation, forms in some measure a character- 
istic difference. In this latter case, however, the diagnosis must 
be chiefly formed, not on the intrinsic merit of any particular 
symptom or appearance, but on the epidemic concurrence of the 
plague at the time in other persons. 



VI. PROGNOSIS. 

From the history which has now been given, the value of many 
of the phenomena of the disease, as indicative of the subsequent 
course which any individual case may take, can in some measure 
be appreciated. It will, not, however, be unprofitable to bring 
together those characters of the disease from which a prognosis 
is chiefly formed. Generally speaking it may be said, that those 
cases are peculiarly favourable in which buboes arise early, and 
go on rapidly through their several stages to a kindly suppura- 
tion, especially if there be an absence of any very marked fever, 
or if there be no or very little vomiting, or if the respiration do 
not correspond with the smallness of the pulse. The condition of 
a bubo is favourable when, at its commencement, it is firm and 
unyielding to the touoh, is not generally adherent, and easily mo- 
vable at its base. In case of fever being a concomitant, it is 
always favourable if there be a copious eruption of buboes only., 
or of carbuncles in great numbers, and with broad surfaces, and 
if the fever itself be open, nor, during its course, attended by 
much cerebral disturbance, but more especially if it subside after 
a gentle perspiration, or even the critical sweat of the third and 
fifth days. The case is always to be judged of favourably, if the 
patient survive to the eighth day, as this argues a state of consti- 
tution which is superior to the influence of the disease : moreover, 
during so protracted a period there are ever symptoms of reaction 
which give great chance of hope that a crisis may occur. This 
period, however, generally takes place about the commencement 
of the second stage, and is marked by the very perceptible less- 
ening of the restless and excitable state of the patient, by the bu- 
boes enlarging, becoming softer, and passing into suppuration: by 
the sudden appearance of several carbuncles with broad bases, 
19 



290 PLAGUE. 

sometimes so large as to be five inches in extent: this condition is 
sometimes accompanied with a papular and vesicular eruption of 
boils and large red blotches, or a tendency to hemorrhage from 
the nose, and in females from the vagina. The pulse is almost 
natural, not exceeding seventy-five, soft, and open; the skin, 
which previously was harsh and dry, becomes soft and bedewed 
with moisture; the tongue loses its sooty coat, which cracks, be- 
comes moist, and peels off; the expression of the eye becomes 
natural, the pupil being no longer dilated nor the conjunctiva in- 
jected: indeed, the whole condition of the patient shows an ame- 
lioration in the symptoms, which, going on favourably, end in 
recovery. 

The circumstances which indicate a fatal termination are, at the 
commencement, a suddenly depressed state of the system unfol- 
lowed by any reactive power, but more especially when accom- 
panied by no eruption of buboes: if, however, any of the febrile 
eruptions do take place, and there is also delirium together with 
excessive cardialgic pains, the prognosis is bad ; but should these 
symptoms not manifest themselves until the second day, they are 
not to be judged of so unfavourably : if the disease go on in its 
course without any excessive fever or cerebral derangement, and 
without evincing any tendency to glandular enlargement, but in 
place of them petechia? or carbuncles make their appearance, an 
unfavourable termination may be anticipated — the occurrence of 
petechise and carbuncles, as evidence of a gangrenous character, 
is to be regarded as unfavourable, especially if these eruptions 
occur in great abundance. The other circumstances which most 
manifestly denote an untoward termination are, a general aspect 
of malignity, as evidenced in a low putrid condition of the sys- 
tem, the non-appearance of matutinal moisture, urgent pains about 
the heart, a drunken expression of the countenance, the muddy 
eye, colliquative diarrhoea, severe vomiting, hemorrhages from 
the mucous surfaces that are constant and not critical, hiccough, 
coma, low muttering delirium, and the sudden clearing up of the 
mental faculties after a period of violent excitement. 



VII. STATISTICS. 

The statistics of plague show that it has been at all times 
attended with the greatest mortality. When this disease raged 
throughout Europe, betwen the years 1347 and 1350, it has been 
computed that a fourth part of the inhabitants of this part of the 
globe were carried off. During the prevalence of this pestilence, 
which has been emphatically called the Black Death of the four- 
teenth century, Hecker says that, without exaggeration, Europe 
lost 25,000,000 of inhabitants. During the time that the plague 



STATISTICS. 291 

raged at Marseilles, in 1720, it is recorded that in the Hopital de la 
Charite there were admitted from the 3d of October to the end 
of February, 1013; and that of these 585 died; and during the 
same period, in the Hopital du Jeu de Mail, from October to the 
3d of July, 1512 were admitted, of whom 820 died. These 
numbers, however, give a higher rate of mortality than the re- 
turns of the disease rendered in the town generally ; this might 
naturally be expected, as only the severer cases would be re- 
moved to the hospitals. The population of Marseilles, previous 
to the occurrence of the disease, was calculated to be about 
90,000, of these 40,000 died, 10,000 only of the whole popula- 
tion not having been in any way affected ; so that it gives the 
enormous mortality of fifty per cent, of those who were attacked 
by plague. M. Gerardin {Mem. de VAcad. Roy. de Med., torn, 
vi.,) gives a very extended notice of the plague as it raged in 
Moscow, in the year 1771; in the course of this he quotes from 
Orr^eus a table of the deaths during the plague year, 1771. In 
April there were 744; in May, 851; in June, 1099; in July, 
1708; in August, 7268; in September, 21,401; in October, 17,- 
561 ; in November, 5235; in December, 805; making a total in 
nine months of 56,772. It is probable, however, that the mor- 
tality was even greater than is here stated, as many dead bodies 
were afterwards found in houses and concealed places, of which 
no report was given, and consequently were not inqluded in the 
report. (Edin. Med. and Surg. Journ., vol. xlix., p. 242.) In 
the returns made to the senate and council of health, the number 
of deaths by plague exceeded 70,000, according to De Mertens, 
and if to these be added the number of those privately and se- 
cretly buried, he thinks it cannot be under 80,000. But the fatal 
effects of this epidemic may be better appreciated from the fol- 
lowing facts : — Between December, 1770,and March, 1771, when 
the great influx of strangers and inhabitants takes place, it was 
calculated that the population amounted to 250,000, and, according 
to some, 300,000. As they begin in March to return to the country, 
it is supposed that at least one-fourth of the inhabitants must be 
absent during the summer season. During the summer of 1771, 
the apprehension of the plague had driven so many from the 
city, that it is believed by De Mertens that in the month of 
August not more than 150,000 remained at Moscow. Allowing, 
therefore, that of this number 80,000 were cut off by the disease, 
it appears that the mortality was at least 53| per cent., or con- 
siderably more than half of the whole population. M. Gerar- 
din estimates the number destroyed by the epidemic to have 
been 60,000 only ; but, according to various documents and con- 
siderations, it is placed as high as 80,000 by De Mertens, who, 
being upon the spot, had good means of information. It is re- 
markable that neither De Mertens, Orr^us, Samoilowitz, 



292 



PLAGUE. 



nor M. Gerardin, in their eagerness to furnish the amount of 
mortality, give us any information on the number of recoveries ; 
being thus left completely in the dark as to the relation of the 
mortality to the numbers attacked by the disease, we are left to 
infer that few or none survived the attack of the epidemic. 
Jackson, in his description of the plague {Account of the Em- 
pire of Morocco) in the empire of Morocco, during the year 
1779, mentions the instance of the small village of Diabet, in 
which 100 persons fell victims to the plague out of 133, the ori- 
ginal population of the village before the visitation of the plague. 
He further says, that "many similar circumstances might be 
adduced relative to the numerous and populous villages dispersed 
through the extensive shelluh province of Haha, all which shared 
a similar or worse fate." Traveling through this province shortly 
after the plague had exhausted itself, he saw many uninhabited 
ruins, which he before had witnessed to be flourishing villages. 
On making inquiry concerning the population of these dismal 
remains, he was informed that, in one village which had con- 
tained 600 inhabitants, four persons only had escaped the ravage. 
Other villages which had contained 400 or 500, had only seven 
or eight survivors left to relate the calamities they had suffered. 
The destruction in the province of Suse was considerably greater 
than elsewhere; Terodant lost, when the infection was at its height, 
about 800 each day; the ruined but still extensive city of Mo- 
rocco lost 1000 each day; the populous cities of Old and New 
Fez, 1200 or 1500; insomuch that, in these extensive cities, the 
mortality was so great that the living had not time to bury the 
dead. 

We shall conclude this division of our subject by quoting the 
following table of mortality, from the effects of plague on the 
population of Smyrna for five months in 1834 : — 



ABSOLUTE NUMBER. 


COMPARATIVE NUMBER. 


In proportion. 


Cases. 


Died. 


Cured. 


Cases Prop. 


Mort.Cases. 


Mort. Pop. 


Turks, - 58,000 
Greeks, - 48,000 
Catholics, - 10,000 
Jews, - 8,000 
Armenians, 6.000 


4500 

600 

50 

457 

120 


4000 
450 

30 
297 

54 


500 

150 

20 

160 

77 


1 : 13 

1 : 80 
1 :200 
1 : 18 
1 : 50 


8 : 9 
3:4 
3 : 5 
2: 3 
3:7 


1 

1 
1 
1 
1 


141 

106 

333 

27 

111 


Total, 130,000 


5727 


4831 


907 


1: 22| 


4:5 


1: 2H 



The singular excess of mortality which the above table shows to 
have taken place amongst the Turks is attributed by Bulard to 



STATISTICS. 293 

their non-attendance to the prophylactic measures, which are re- 
sorted to by other sects living in the East. 

Mortality, however, in plague, is influenced very considerably 
by many circumstances, as age, profession, climate, &c. 

Infants, when born of parents suffering under the influence of 
plague, have occasionally on their person some marks of the dis- 
ease. These are never known to survive ; nor, indeed, do they, 
when born under such circumstances, though they have appa- 
rently none of the usual plague eruptions about them. It has 
been commonly observed that the young, healthy, and robust, 
are the most susceptible of plague influence, then women and 
children, and, least of all, thin, sickly, emaciated, old men. We 
have already alluded to the tendency which women have to ex- 
cessive and unusual uterine discharge, and in case of pregnancy 
to premature labour. This, provided the symptoms assume a 
putrid character, adds very considerably to the danger of their 
situation ; otherwise, the flux of blood is often attended by bene- 
ficial results. Dr. Brown does not, however, view this as a 
critical discharge, but as an evidence of returning health. Not- 
withstanding this chance against the adult female, observation 
has shown that in them, as is the case in children and sickly old 
men, the liability to perish under the poisonous influence of the 
disease is not so great as in robust adult men. Bulard, how- 
ever, says, that " sex produces no marked difference." 

Occupation, as may naturally be supposed, influences some- 
what the liability to the disease. Generally those whose labour 
exposes them to mid-day heats, under circumstances of privation, 
are particularly susceptible. Russell says, that bakers are very 
liable to it, and that they have been observed to suffer in a re- 
markable proportion ; and suggests, that as the loss of these peo- 
ple during a pestilence is most serious, their safety should be 
particularly looked to. In the historical account of plague as it 
occurred at Marseilles, we find the following summary of mor- 
tality in different trades: — "Of 100 manufacturing hatters, there 
died 53; of 134 house-carpenters, 84 ; of 138 tailors, 78; of 200 
shoemakers, 110; of 400 cobblers, 50; and of 500 masons, 350; 
of persons in a still lower station of life, such as porters and chair- 
men, the mortality was very great indeed ; scarcely a sixth part 
remaining at the close of the epidemic." 

Situation, climate, and season of the year, there can be no 
doubt, are very essential elements in the production of the pecu- 
liar virus which originates plague. Though it may be impossible 
for us to explain how this may be, yet the recorded facts of many 
centuries offer evidence short only of the most positive proof. 
In respect to situation and climate, it has long been observed, that 
certain localities in the East, as Constantinople, Smyrna, Cairo, 



294 



PLAGUE. 



and the towns towards the Mouths of the Nile, are most fre- 
quently prone to be ravaged by it ; and that it occurs in these 
places, not only with epidemical severity in certain seasons, 
which experience has shown are the more congenial to the spread 
of its morbific powers, but that they are rarely found to be with- 
out some few cases which sporadically occur. In fact Abbot, 
Pruner, and Gregson (Holroyd's Letter on the Quarantine 
Laws), state that they believe Egypt never to be free from it ; 
nor that it ever will be entirely so, as long as the conditions, 
which now predominate in the climatical exposition and in its 
interior disposition, continue. Though there may, from certain 
circumstances, be every reason to suppose that these situations and 
the climates proper to them possess the generating powers requi- 
site to originate the disease, yet, at the same time, other circum- 
stances occasionally occur, which militate against its either being 
exclusively owing to one or to the other, as is clearly evidenced 
by the occasional occurrence of plague in other and more distant 
places, and which appear in no respect to have anything in com- 
mon with the eastern districts. A very extended observation 
would appear, however, to warrant the conclusion, that plague 
can arise in no other portion of the globe than that which is in- 
cluded between the tropic of cancer and the sixtieth degree of 
north latitude. Season of the year has, in like manner, a gene- 
ral influence, both upon the origin and progress of this disease ; 
but there are also exceptions to its exerting any exclusive power. 
The common impression in the East is, that plague is arrested in 
its course by excessive degrees, either of heat or cold, and that 
an intermediate temperature favours its spread. Sir Gilbert 
Blane [Select Dissertations) says, " the experience of ages has 
incontestably established it, that the disease of the plague cannot 
co-exist with a heat of atmosphere above 80°, nor a little below 
60°." This idea has been formed, and very justly so, on the 
fact, that in the East the plague, which usually commences in the 
spring of the year, subsides on the advent of summer ; while in 
Europe it usually occurs at the commencement of, and continues 
through the summer, but subsides as winter advances ; thus, 
towards the end of September, but still more sensibly in the 
second week of October, the plague, when occurring in London, 
has usually been observed to decline ; and its decrease in No- 
vember has been always rapid. This has been the ordinary 
tenour of its course, from which it has rarely deviated more than 
a few days. (Russell, op. cit.) Though this is what ordi- 
narily takes place, yet now and then circumstances occur, which 
at once destroy any positive conclusions upon the subject ; for 
instance, in 1813 it raged in Malta during the summer, and in 
Corfu during the winter; similar anomalies were observed in 



STATISTICS. 295 

England during its prevalence in the early part of the seven- 
teenth century. 

The decrease of plague in the East towards the middle of June 
is so remarkable, that, at Cairo, St. John's Day, which is the 24th 
of June, is ever understood amongst the superstitious inhabitants 
of these districts to put a period to the disease. The uniformity 
of its decrease as the summer advances is so very marked, that 
those persons who have previously confined themselves invari- 
ably on this day come forth, mix with other people, transact their 
ordinary affairs, and in no respect restrain themselves on account 
of any fear of taking the disease. It is generally supposed 
throughout Egypt that the heavy nycta, or mildews, which begin 
to fall about this period of the year, form the condition upon 
which depends the arresting the progress of the disease. There 
has been, however, no corroborative fact noticed, which enables 
us to infer that any condition of dryness, or of moisture, possesses 
this peculiar influence upon the disease. Gregory says, that " it 
is a common remark in the Levant, that the advances of the 
plague are always from south to north ; and that, when plague is 
at Smyrna, the inhabitants of Aleppo handle goods without pre- 
caution, and have no fears of contagion; when the disease, on. 
the other hand, is at Damascus, great precautions are observed, 
and all the Frank families hold themselves in readiness to shut 
up, or to leave the town." 

Plague usually lasts as an epidemic for the space of three or 
four months. In the East, from whence the history is best filled 
up, it usually commences about March, by a few solitary cases of 
the utmost severity : the great mortality then commences, and is 
maintained with fluctuating variations until the period of its de- 
cline. This is sometimes remarkably sudden. Such a progress 
marked its occurrence at Marseilles in 1720. It is described as 
having advanced rapidly in August, raged through that month 
and September, and that its decline in October was almost as 
sudden as its commencement had been in August. This mode of 
its ceasing appears to obtain in all places, whatever may have 
been its duration, or whatever may have been the means em- 
ployed against it, whether precautionary or curative. During the 
progress of the epidemic, there are evidently three periods in the 
course of which the mortality very considerably varies. At its 
commencement the disease is not very widely disseminated, but 
its relative mortality is greatest ; as it arrives at its height the 
population is more universally infected, but the relative number 
of deaths is very materially diminished ; and at its decline both 
the number of cases and the relative mortality are decreased to a 
sudden and remarkable extent. 

It has generally been supposed that animals are earlier suscep- 



296 PLAGUE. 

tible of the influences which produce plague than man. This 
belief is grounded on the fact that, previous to this disease be- 
coming epidemic, epizootic affections have been observed almost 
universally to attack cattle, under the effects of which great num- 
bers of them perish ; that birds desert the spot ; that insects be- 
come more numerous; and that frogs are more vociferous. On 
some of these points there are the most decided and incontestable 
evidences. Hodges mentions the mortality of cattle in London, 
previous to the plague of 1565, as being very considerable. The 
medical faculty of Paris, during the prevalence of the black death 
in the fourteenth century, were commissioned to deliver their 
opinion on its causes. In this document they mention great mor- 
tality amongst fish; but the most distinct and valuable testimony 
upon this point is that of Dr. Gregson, (Holroyd's Letter.) 
He says, before the disease broke out, (1835,) a number of the 
Pacha's oxen were seized with a malady of which above one 
hundred died in a few days, and that he was sent to investigate 
and report on this epidemic. On examination he found gastritis 
and enteritis in the most intense degree, to such an extent, indeed, 
that he met with extensive gangrene in oxen, which had been ob- 
served ill but twelve hours. They also had large buboes. This 
he reported to be plague, and caused them to be interred deeply. 
Of animals dying during the prevalence of plague, there are 
numerous instances on record. Boccacio, who has given by no 
means the least instructive history of the epidemic of the four- 
teenth century, alludes to the mortality amongst animals, and 
details his having seen two hogs affected by it, which, after stag- 
gering about for a short time, fell down dead, as if they had 
taken poison. Hecker observes, that "in other places multi- 
tudes of dogs, cats, fowls, and other animals, fell victims to the 
contagion." Bulard inserted the serum from the carbuncles, 
and the pus from the buboes, and the blood from the heart and 
veins, &c., of those infected, into the subcutaneous cellular tissue 
of dogs and other animals ; he also caused them to eat the same 
pathological products, but never succeeded in thus communicating 
the disease. 



VIII. NATURE OF PLAGUE. 

The phenomena attending the development of plague during 
life, and the lesions observed after death, do not enable us satis- 
factorily to decide upon its proximate cause or nature. Those 
writers who have entertained theories upon fevers generally, 
apply them most complacently to plague ; and without much 
effort, but some little ambiguity, reconcile all that takes place to 
their favourite views. We shall not, however, dwell upon the 



NATURE OF PLAGUE. 297 

"considerable spasm and loss of tone in the extreme vessels" of 
Cullen; nor upon the gastro-enteritis of Broussais, the frequent 
absence of which, even to "the period of death, he explains by- 
saying it has not had time to develop itself; nor to the equally- 
puerile views of another pathologist, who states plague to be an 
inflammation of the bronchial tubes — comparatively speaking, a 
very rare seat of lesion in this disease ; nor upon several others 
which might be named, but content ourselves by giving a short 
abstract of the opinions entertained by Craigie and Bulard. 
The former of these writers applies the general view which he 
advocates, namely, that it is owing to derangement of the capil- 
lary system. In reference to the disease now under consideration, 
he says, that "the remote material agent which causes it, what- 
ever that may be, acts upon the capillary T vessels immediately or 
secondarily through their contents, in every tissue and every organ 
of the human body. The result of which is, that the fluids are 
no longer freely transmitted through them, so that there is pro- 
duced a sudden and almost immediate retardation of the motion 
of the blood through the capillaries of the whole system." He 
infers this to be the case from the four following circumstances: — 
" 1st. That the arteries of the brain and its investments, of the 
stomach, of the intestinal tube, and of the secreting glands, are 
distended with dark-coloured semi-fluid blood ; 2dly. Because the 
vessels of all the organs are much loaded with dark-coloured fluid 
blood, which escapes immediately on the smallest incisions ; 3dly. 
Because in several of the organs, for instance the brain, the lungs, 
the liver, the kidneys, and other solid organs, nay, even in the 
muscles, dark-coloured half-coagulated blood is found fixed in 
clusters of vessels so as to form dark or carbonaceous patches and 
masses ; and, 4thly. Because dark grumous blood is found, not 
only in the right chambers of the heart, but in the left auricle and 
ventricle, in which they are not usually found in ordinary death. 
( Practice of Physic. ) 

Bulard is not less ingenious. He states plague to be the con- 
tagious product of lymphatic absorption. This view is grounded 
upon the statement, that the only symptom which has been 
remarked as alone and distinct from any other at the commence- 
ment of the disease, is pain in the lymphatic glands. This is at 
first but a slight throbbing, becoming more violent and continued, 
and ultimately succeeded by swelling and buboes. This change 
in the lymphatic glands is the only lesion which is to be found 
totally isolated from all others, and it is consequent upon changes 
in the lymph ; and, therefore, each, during the local affections, is 
to be considered only as consecutive to this disorder in the lym- 
phatic system ; in which consists the simple original affection, the 
essence of the disease, and without which no general disturbance 



298 



PLAGUE. 



could have occurred. This view Bulard supports on the grounds 
that the whole system of lymphatic vessels, whether going from 
or to the gland, is not diseased, but only the glands themselves ; 
therefore, he argues, that, as these are always diseased and the 
vessels never, it is evident that the malady is not conveyed by 
continuity of tissue, but that the diseased principle is introduced 
into the lymphatic circulation ; and, therefore, the alteration of the 
lymph is cause and reason sufficient for the phenomena of dis- 
eased absorption, the pathological effects of which are displayed 
on the glands. The disease, therefore, arises from a change in 
the lymph. This constitutes the primary affection, the secondary 
effect of which is, that as this degeneration in the lymphatic fluids 
becomes more or less advanced, the blood itself becomes decom- 
posed by the morbid lymph entering into its composition by the 
venous circulation. It thus loses its normal qualities, and then 
causes a general disturbance, a deep disorganization in all its 
functions; in shortfall the derangements of a true poisoning. 
From this moment it loses its physiological character, and assumes 
one entirely peculiar to itself: and hence are to be explained the 
lesions met with throughout the system — the livid colour of the 
stomach, the swollen state of its mucous membrane, the softened 
state of the spleen, gorged as it is with a black grumous blood, 
the enlarged and softened condition of the heart, &e. ; in fact, 
every lesion which has been mentioned. Hecker, in his account 
of the black death, reverses the theory of Bulard, stating that the 
blood is first attacked through the atmospheric poison acting on 
the organs of respiration ; and that' the inflammation in the lym- 
phatic glands and other organs is only consequent upon the change 
thus effected in the vital fluid. 



IX. CAUSES. 

Numerous conflicting opinions have been entertained as to the 
origin and spread of plague. We shall endeavour to condense 
this often discussed inquiry. The first point that naturally pre- 
sents itself is to determine, if possible, the original source of the 
disease. It has already been stated, that plague is of very con- 
stant occurrence in some parts of Egypt and Greece, in Syria and 
Asia Minor ; in which countries it not only exists in particular 
times epidemically, but isolated, or, as they are technically termed, 
sporadic cases are always to be met with. Wherefore we may 
infer that the causes which primarily produce plague are indi- 
genous, and always more or less in active operation. What its 
source may be is, however, very difficult to determine ; some 
imagine that it arises from miasms which are consequent upon 
the retiring of the Nile after its periodical overflowings, when it 



causes. 299 

leaves behind it a slimy deposit. Many arguments may, how- 
ever, be urged against this. The numerous villages situated in 
the morass are neither the first nor the most constantly affected ; 
on the contrary, observation proves that it first originates in towns 
situated on the sea-coast, and that in these places the mortality is 
ever the largest. 

[Dr. Clot Bey says, that those who attribute plague to the 
overflow of the Nile, are ignorant of the nature of this overflow. 
The residue which is left by the Nile is nothing but pure earthy 
soil, without any admixture of vegetable or animal matter ; the 
layer deposited is not much thicker than a sheet of paper, and it 
is even doubtful whether the irrigation be favourable to vegeta- 
tion, so small is the quantity of alluvial matter lodged by the 
waters. Other writers speak of evaporation or exhalations from 
the Nile, which bring with them decayed vegetable matter from the 
marshes traversed during its course. Were this the case, plague 
should be most prevalent in Upper Egypt, where such marshes 
exist, and in Nubia; but it is almost unknown in these countries. 
The truth is, that very false ideas prevail concerning the overflow 
of the Nile. The inundation of Egypt is completely artificial, and 
takes place only when it is thought advisable to effect it by open- 
ing the dykes. Any extensive inundation is the result of acci- 
dent ; but even then it has not been observed that plague prevails 
more extensively, or with greater intensity, than at other times.] 

Nor is it probable that it has its origin from the soil, not only 
because no peculiarities have been pointed out in this respect, but 
that it arises in soils of a totally different nature. We are, there- 
fore, reduced to the belief, that plague is owing to certain occa- 
sional physical conditions, proper to the climate, and which may 
be termed its pestilential constitution. At the same time there 
can be no doubt that the habits of the people who inhabit this 
district, and the filth of their towns, engender a susceptibility of 
the influences which produce the disease. Some, and among 
these are Desgennettes, Savaresi, Assalini, Larrey, &c, 
even go so far as to believe that in these circumstances alone there 
is sufficient cause for its origin. Dr. Hancock, ( Cyc. Prac. Med.,) 
who entertains likewise this view of the connection of pestilence 
with filth, attributes its non-occurrence in recent years in some 
cities, where formerly it occasionally committed its devastations, 
to a state of cleanliness and ventilation having superseded their 
previous state of filth and pent-up vapours. [Dr. Clot Bey ob- 
serves, were this the fact, plague would be frequent in Upper 
Egypt, where it is unknown.] 

From what has been said there is every reason to infer, that 
plague originally depends upon the action of some local influence, 
probably atmospheric, the nature of which, with all our increased 



300 PLAGUE. 

resources of extended knowledge, we are as totally incapable of 
understanding as our ancestors in the fourteenth century. We, 
however, observe that, in certain places, the disease so originated 
becomes diffused, and acquires what is termed an epidemic ex- 
istence. It is highly important to inquire, whether this effect 
takes place solely through the immediate and still operating in- 
fluence which originally engendered it, or whether the disease is 
contagious, or propagated by the miasm exhaled from the bodies 
of persons affected with plague. 

Let us shortly examine the grounds upon which the doctrines 
of contagion are advocated. 

First, as regards inoculation. Various cases are recorded of 
individuals in good health inoculating themselves with matter 
taken from buboes and carbuncles of plague patients. Very 
different results have followed this operation. In some instances 
the symptoms of plague have appeared, while in others the only 
effect was slight local irritation, as might be anticipated from 
inserting a poisonous fluid matter into the cellular membrane. 
But even had plague occurred in all these cases, no satisfactory 
conclusion could be deduced from the fact of their having been 
performed in situations where the disease was prevalent at the 
time. In order fairly to test the question, it would be necessary 
to institute a most unjustifiable series of experiments, namely, the 
inoculating with plague products persons living at a distance 
from the localities where this disease occurs, and who could have 
no communication either direct or intermediate with plague cases, 
except through the matter with which the experiment is made. 

Secondly. The other modes by which plague, according to the 
contagionists, may be propagated, are by immediate contact with 
the person diseased ; by exhalations from the persons of the sick ; 
by fomites, or the imbibition of the pestilential vapour ; by certain 
substances which are supposed to be capable of retaining it in 
such a state of activity as to have the power of regenerating the 
disease. This mode of propagation is esteemed to be more potent 
than either contact or miasmatic atmosphere. With regard to its 
propagation by immediate contact, Russell holds it to be an 
undeniable fact, that the plague is thus communicable, but that 
it is not ascertained at what particular stage of the disorder it is 
the most infectious. Some have laid it down as an established 
law, that the poison of the plague is so fixed that, in order to be 
infected, contact is absolutely necessary, and that the disease may 
be communicated no other way, unless by inhaling the pestiferous 
breath of the patient. 

The chief facts on which it is presumed that the plague is com- 
municated by exhalation from the bodies of the diseased, are the 



CAUSES. 301 

modes in which it has commenced and spread in places where it 
has raged. Of these facts the following is a summary: — It is 
stated that the plague has been introduced into a district pre- 
viously healthy, immediately after the arrival of an infected per- 
son ; or that the first individual attacked has had intercourse with 
some person affected with the disease or recently recovered from 
it ; or has been exposed to the influence of imported fomites, 
conveyed in various species of merchandize, especially bales of 
cotton, flax, &c. ; and that where a perfect exclusion of all com- 
munication with the diseased districts can be effected by means of 
a strong cordon, complete security is obtained, although the dis- 
order is raging violently without that circle. 

The objections made to these views by those who maintain 
that the disease is solely caused by endemic influences are : — 1. 
That a miasm emanating directly from a plague patient, or the 
transmission of the disease intermediately by fomites, are facts by 
no means conclusively proved ; that, in truth, the whole state- 
ments in favour of contagion are imperfect and unsatisfactory. 
2. That certain places, when the immediate neighbourhood was 
under the influence of plague, have not been kept healthy by 
means of quarantine regulations. It has often been shown, that 
in such situations some few cases have occurred, but that the dis- 
ease has not spread ; which immunity has been attributed to the 
ventilation and internal discipline rendering those within the cor- 
don less susceptible of the epidemic influences. 3. That many 
of those who are in the most constant communication with the 
sick do not take the disease ; that the attendants, who perform all 
the necessary offices, as well as the medical men, escape; and that 
many who have advocated the doctrines of anti-contagion, have 
ventured with impunity upon the more rash and hazardous ex- 
periments of tasting the secretious, wearing the clothes, and sleep- 
ing in the beds of those affected. That those engaged in burying 
the dead are not more subject to plague than other persons; "and 
that sexual intercourse has even been known to have taken place 
without communicating the disease. 4. That the evidence of 
plague being communicated by inoculation is anything but satis- 
factory. It has already been remarked, that to make the experi- 
ment conclusive, the person to be inoculated with plague matter 
should be living in some district far from the local or general in- 
fluence's of the disease. On the contrary, those cases previously 
referred to, where this method produced no results, go far to nega- 
tive the communicability of the disease through the medium of 
pus, or other plague products introduced into the system by inocu- 
lation. 5. That the occurrence of sporadic cases is conclusive 
against the notion that contagion is the sole origin of plague; and 
that the existence of those cases, without spreading the disease, 



302 PLAGUE 

is a fact which militates greatly against its being contagious at all. 
It is evident that the occurrence of isolated cases in large cities, 
which is not unfrequent, is a fact totally irreconcilable with the 
doctrines of contagion as sanctioned by its advocates. 6. That 
when the disease becomes 'prevalent in a district, it is found to 
occur in situations and among individuals where there is the least 
possible communication with the infected, and that it frequently 
breaks out in remote and separate parts of a town, without any 
traceable intercourse or communication. 7. That in maritime 
towns, where it is said to have been imported, it frequently hap- 
pens that those who are the first affected live in parts which are 
distant from the shore, and therefore not in the nearest and most 
likely places to receive the infection. 8. That it is found to arrive 
in many localities at the same time, and this applies both to the 
country and to towns. In the East it is frequently observed to 
arise within a few days in places which are not only very distant, 
but under circumstances which prevented communication ; and 
to occur in like manner simultaneously in different parts of the 
same town — facts which evidently show a more diffused influ- 
ence than is probable on the supposition of human contagion. 9. 
That notwithstanding all the very curious and ingenious modes 
in which the propagation of plague has been said to have taken 
place, the possibility of which it requires a very large share of 
oriental credulity to believe, the disease is really very difficult to 
propagate by any means which as yet have been devised by man. 
Many instances of adventurous experiment, made without suc- 
cess, sufficiently prove this. 10. That numerous instances may 
be quoted, of large masses of persons moving from an infected 
district without carrying the disease with them. The contagion'- 
ists state, that immense multitudes of hadjis, or pilgrims, who go 
every year from Turkey to Arabia, through both Syria and Egypt, 
are the instruments by which the plague is spread in the coun- 
tries thus visited by them. So far, however, is this from being 
the case, that the marches of these people in different years take 
place at different seasons, while plague is a disease more espe- 
cially of one season ; and that, excepting when these marches of 
the Mussulmen coincide with the plague season, their progress is 
not characterized by its occurrence ; and, moreover, that many of 
the districts through which they pass during their pilgrimage are 
never known to suffer. That in 1824, when the plague raged so 
fiercely in European Turkey, many thousand Turkish pilgrims 
passed through Alexandria on their way to the Holy City ; but 
in Alexandria there was only one case of plague, though no pre- 
cautions were taken, and no quarantine regulations then existed 
to interrupt their progress. 11. That plague is a disease of en- 
demic origin, and therefore that all those cases which are said to 
have been caused by contagion, are really owing to endemic in- 



CAUSES. 303 

fluences. 12. That the spontaneous and sudden decline of plague 
at a particular season disproves the operation of a contagious 
principle, this being evidence that plague is influenced by clima- 
torial changes — a condition which the advocates of contagion do 
not suppose consonant with its laws. That, on the other hand, it 
proves plague to be owing to some endemic influence which has 
now ceased to exist. That, on this periodic cessation taking place 
in the countries which are the most frequent seats of the disease, 
the inhabitants lose all dread, and, from experience, know that 
without any evil consequences they may meet each other, visit 
the sick, wear the clothes of those who have died. 13. That, 
besides the above more general arguments against contagion, an 
inference to the same effect may be drawn from the fact that, 
before plague sets in, especially in such countries where it is of 
more rare occurrence, diseases of a putrid character and fatal tend- 
ency are prevalent; and that epizootic affections take place, 
which frequently cause great mortality amongst animals. 

We believe that we have briefly, though fairly, stated the views 
of those who advocate the plague to be a contagious disease, as 
likewise the chief objections offered to these views by the anti- 
contagionists. It has been seen that the statements of each party 
are sufficiently contrary; it may, therefore, be supposed to be 
somewhat difficult to arrive at any decided opinion upon the 
question. We are, however, inclined to believe that plague is 
essentially an endemic disease ; that the causes, though unappre- 
ciable by us, become at times, from circumstances connected with 
season, which we likewise do not comprehend, so active and 
potent in their influences as to produce what is termed an epi- 
demic ; and that, when not occurring epidemically in those coun- 
tries where such an effect often takes place, the causes are either 
dormant or only in a state of very partial or slight activity. That, 
during the continuance of the epidemic effect, a principle is given 
off from the body, which, if very concentrated, and pent up in 
confined and unwholesome situations, may generate the disease, 
so that, though not originally contagious, it may, in this way, by 
accumulation of animal miasms, be contagious ; and that it is not 
improbable, when the disease is communicated from person to 
person, it is by the inhaling the pestiferous breath or exhalations 
which emanate from the body of the patient; but at the same 
time that this influence of the atmosphere of contagion is very 
limited in its power and extent. That a person who is himself 
uninfected cannot produce the disease in others by being, as it 
were, the bearer of it. That the communication of plague by 
inoculation with the matter from a bubo, or with any other mor- 
bid product, has by no means been proved ; on the contrary, there 
is every reason to believe that the disease cannot be produced by 



304 PLAGUE. 

these means. That fomites in themselves have no power of trans- 
mitting the disease. That those who have long dwelt in a place 
where plague has existed for some time, become, as it were, for- 
tified against its influences, and are therefore less disposed to be 
affected than those who come fresh into the pestilential atmo- 
sphere. 

[The non-contagionists found their arguments against the pro- 
pagation of plague by contagion, or infection, chiefly on the fact 
of its being a local disease, indigenous to the certain regions, 
where it prevails endemically and epidemically, being generated 
by certain meteorological or atmospheric conditions, entirely un- 
known, which they call the pestilential constitution; that it 
observes the same course as other epidemics, having a period 
of commencement, intensity, and decline ; that it has a regular 
season; that Persia, though surrounded by the disease, very 
rarely suffers from it; that, although 70,000 or 80,000 pilgrims 
annually visit Mecca from plague districts, carrying merchandize 
from infected places, the disease rarely spreads ; that the clothes 
of many thousands who annually die of plague are publicly sold 
after St. John's day, and that there is no evidence that those who 
purchase and wear them, catch the disorder ; that inoculation has 
been practised with impunity; that it has appeared in localities 
where the strictest quarantine has existed ; and that persons in 
constant intercourse with plague-patients escape the disease. 

Admitting the correctness of these assertions, they are merely 
negative facts, to which positive facts, stated on undoubted autho- 
rity, may be opposed. All that has been urged against the con- 
tagiousness of plague, applies with equal force in the case of 
diseases notoriously contagious — as small-pox, typhus fever, scar- 
latina, and measles. These diseases arise, or become epidemic 
from some atmospheric or terrestrial cause, rage for a certain 
time, and finally, when the epidemic cause ceases, decline. Dur- 
ing their prevalence they spread both from an epidemic cause as 
well as by contagion. Diseases, in their commencement non- 
contagious, may acquire in their progress the property of infec- 
tion, from high concentration of the original cause, or from gene- 
rating an infected atmosphere. {Ferguson.) 

A disease that can be communicated by inoculation must be con- 
tagious. Although the evidence of the communicability of plague 
by inoculation is, it must be admitted, contradictory, still there are 
several recorded facts by creditable authorities, which leave no 
doubt of the fact on our mind. As it is urged that the experiments 
are made during an epidemic, it is of course not demonstrable that 
the disease was not independent of inoculation. This argument 
is scarcely tenable in the following case, where it appears a car- 
buncle formed at the seat of puncture. Dr. Grassi, Protomedico 



CAUSES. 305 

di Sarrita at Alexandria, mentions the case of a physician who 
pricked himself on the ring finger of the left hand, in opening the 
dead body of a plague-patient. Four days subsequently, he was* 
attacked with headache, pains in the small of the back, vomiting, 
and chills, which lasted until the following day, when he remarked 
on the finger a small phlyctena, and the corresponding axilla soon 
became swollen, and painful. The next day delirium occurred, 
and plague carbuncle and bubo were developed in the finger and 
axilla. He ultimately recovered. 

When a disease appears in a previously healthy locality after 
the arrival there of persons or merchandize from infected districts, 
and when the first victims of the new disease are those who have 
had direct communication with the diseased comers, or the in- 
fected merchandize,there is good reason to believe that such disease 
is propagated by contagion. On the 29th of March, IS 13, a ship 
arrived at Malta — which place had been previously free from any 
visitation of plague for 130 years — from Alexandria, where the 
plague was raging at the time of her departure, and two of the crew 
had died of it on the passage. The ship anchored, and lay in the 
harbour, close to the city of Valetta. The master died three days 
after her arrival. Remonstrances were made to the commander- 
in-chief for the removal of the vessel ; but they were unheeded. 
On the 16th of April, the first case of plague occurred. The 
quarantine regulations had been lax. The first cases were in the 
house of a person named Borg, who with two others of his family 
were attacked. Some linen, which corresponded with that of a 
missing bale from the ship, was found in the house, and Borg died 
crying " Oh the linen, the linen/' The next house attacked was 
that of a school mistress, a friend of Borg, who had attended him 
during his illness; and the progress of the disease was also clearly 
traced through her scholars. On June 8th, 1841, a merchant ves- 
sel arrived at Constantinople from Alexandria, with several cases 
of plague on board. Constantinople and the neighbourhood had 
been free from plague for three years previously. A lazaretto 
guardian, in perfect health, was sent on board, and assisted in land- 
ing the patients. He was taken ill on the 13th, and died on the 
15th, with bubo and every symptom of plague. A porter, also, 
on the 22d, was found to have had symptoms of plague for two 
days, and a very large bubo in the left groin followed. He was 
conveyed to the pest-house and recovered. Two other persons 
connected with the lazaretto died. On the 26th of May, 1841, a 
vessel arrived in Malta, from Alexandria, with plague on board. 
The crew, and two boatmen who communicated with the vessel, 
were segregated. One of the boatmen was attacked with plague 
and died. A similar instance occurred in 1821, when an infected 
vessel arrived from Alexandria, and thirteen of its crew or pass- 
engers died of plague in the lazaretto. A Maltese who had had 
20 



306 PLAGUE. 

the disease in 1813, believed himself protected, and volunteered 
to be the nurse. He was attacked with the symptoms of plague 
after eight days attendance. Other as undeniable instances could 
be adduced were it necessary. The first case is a striking proof 
of the importation of the disease into a healthy community, and of 
those who were first affected communicating the disease. In the 
second case, in a city of 800,000 inhabitants, free from epidemic 
influence, those brought in contact with the infected persons alone 
suffer. This case, Dr. John Davy says, " carried conviction to 
his mind, previously in doubt on the subject." 

They bear, also, on another proof of contagion — that those in 
close connection with the sick, are the chief, or only sufferers. Dr. 
Clot Bey acknowledges that, « many employees, but especially 
those who are most in connection with the patients," contract the 
disease, and die. Dr. Robert Williams [Morbid Poisons, p. 
284), cites a number of striking facts confirmatory of this position. 
" The French army, on first taking possession of Egypt, lost no 
less than eighty medical officers by the plague, an immense pro- 
portion, compared with that of the army generally. * * * At 
length the French resorted to the expedient of employing Turkish 
barbers to dress carbuncles, buboes, and blisters, as well as to bleed 
the plague-patients ; and after the adoption of this measure only 
twelve medical officers died in twice the former space of time. 
* * * In the English army, of 7883 Europeans and native 
Sepoys, only 165 died of plague, or about 1 in 4S; yet, of 13 
medical officers, seven died of this disease, or more than half." 
Similar facts will be noticed in treating of the effects of segre- 
gation. 

Another proof of one of the modes of propagation of plague 
being by contagion, is the preservative influence of a separation 
of the infected from the healthy. We have already seen in- 
stances of this in the effects of strict quarantine in confining the 
disease within the lazarettos of Constantinople. In Malta, dur- 
ing the plague of 1813, when, out of a population of 90,000, 4486 
deaths took place, between April and November, a whole city, 
closely shut up, enjoyed total exemption, though only 260 yards 
from Valetta, where the plague was raging. The same epidemic 
furnishes an example of plague being kept within a city, by the 
same means. In the village of Curni, only, plague lingered, when 
the remainder of the island was admitted to free intercourse ; the 
authorities had it surrounded by a wall and a cordon of sentinels. 
The rest of the inhabitants pursued their usual avocations, and 
none of them contracted the disease. The convent of St. Augus- 
tine had been in strict quarantine, until a servant purchased some 
old clothes from an infected quarter; he was taken ill; a monk 
who volunteered to attend him, was placed with him in a sepa- 
rate apartment, caught the disease, and both died. At Moscow, 



CAUSES. 307 

in 1770-71, the Foundling Hospital was "shut up," and the 
inmates, 1400 in number, were completely secluded. Some of 
the workmen got over the fences in the night-time, and were im- 
mediately attacked with the disease. They were promptly sepa- 
rated from the rest, and it did not spread. At Marseilles, in 
1720, the bishop certified that " the plague had not penetrated into 
the religious communities, who had not held any communication 
with persons without." ( Williams, p. 282.) The Naval Hospital 
at Malta was strictly insulated, and the only case that occurred, 
was in the person of the market man, who had strayed into an 
infected family. The inmates of the nunneries, prisons and con- 
vents, with the solitary instance just mentioned, enjoyed perfect 
immunity. Dr. Grassi states, that, during the plague in Alexan- 
dria in 1834, the squadron of 16,000 persons escaped, not from 
removal from the seat of infection, because other ships which had 
communication with the shore, lost many men, but from com- 
plete segregation. The arsenal, with 6,000 labourers, close to the 
infected quarter, was kept in strict quarantine ; there was no de- 
cided case of plague. The Marine Hospital, although surrounded 
by three villages which were completely deserted from the effects 
of plague, remained healthy during the long time the plague 
lasted, a strict quarantine being maintained within its limits. At 
the Land Hospital, where the physician was a non-contagionist, 
and no precautionary measures were taken, the disease carried off 
many victims, and subjected the government to great sacrifices. 
During this plague, the college with its hospital, the populous 
harem of the viceroy, other establishments, and numerous private 
families were "shut up," and entirely escaped; while, of the Turks, 
who took no precautions, it is said that, on the decline of the dis- 
ease, more than 100 keys were found at the police, of houses 
whose inhabitants had all perished. Dr. Gaetani Bey says 
« that in 32,525 persons isolated in quarantine, not one case of 
plague has been proved." Dr. Floquin gives another instance 
of the effects of segregation. " During the plague of 1837, 8 to 
10,000 persons died in Smyrna, of a population of 40,000 Mus- 
sulmen, whilst scarcely 1000 died of a population of 55,000 Chris- 
tians. Dr. Grassi shows that from 1831 to 1837, " the plague 
has ten times reached the port of Alexandria from without; that 
it has been eight times combated and subdued in the lazaretto ; 
and in the two instances in which it penetrated into Egypt, the 
cause was the non-adoption of similar regulations." 

We shall now briefly examine the mode of propagation by 
fomites, as on this belief are founded the laws of quarantine. The 
evidence on this point is contradictory. Bulard says " that this 
mode of transmission, in the actual state of science, can neither 
be sustained, nor combated logically." Sir James M'Grigor, in 
evidence before a parliamentary committee, stated, that he could 



308 PLAGUE. 

speak with certainty of both the clothing of the men, and of 
blankets having conveyed it. An Armenian banker quitted pre- 
cipitately his country-seat on the Bosphorus, in consequence of 
a case of plague occurring amongst his domestics. Everything 
was tolerably well purified in the usual manner, with the ex- 
ception of a couple of trunks, containing fur, shawls, &c. The 
following spring, the proprietor wishing again to occupy his sum- 
mer residence, ordered his servants to open the trunks with pre- 
caution, and air the contents. Two of the number were attacked 
and died of plague, though at the same time the public health was 
good. {Report to House of Commons, #c.) The officers of the 
French army, when in Italy, became so convinced that clothing 
communicated the disease, that Napoleon ordered all such captured 
articles to be burnt. A man in the village of Curmi (before alluded 
to), stole, and buried in a box, some articles of wearing apparel. 
Upwards of two months after the plague had ceased in. Casal 
Curmi, this man dug up the box, and carried it to the island of 
Gozo, which island had adopted the strictest quarantine, and had 
remained till this time free from the plague. At a marriage in 
his family, he opened this box, to present a silk covering for the 
head to the bride. He, the female, and the priest, all became affected 
with plague from that day and died. From that family the dis- 
ease spread to others, till it pervaded the island. This fact was 
recorded in a government dispatch of Sir Thomas Maitland. 
There is, then, we think, good reason to believe that the clothes of 
plague-patients not exposed to the air and light, may and do com- 
municate the disease. There is no sufficient proof that there is 
danger of contagion from merchandize, or the clothes and bed- 
ding of plague-patients which have been exposed to the air. 

Plague we regard to be like small-pox, both contagious and 
infectious. Actual contact alone is not dangerous, but close ap- 
proach is probably necessary, the infecting distance being but 
small, a certain dilution of the atmospheric air rendering the ema- 
nations harmless. 

For much valuable information on this subject, consult two ex- 
cellent articles in the British and Foreign Medical Review, for 
October, 1843, and January, 1845 ; also a contribution of the late 
Dr. Ferguson, the Inspector General of Army Hospitals, on the 
Importation and Propagation of Plague, in the Edinburgh Medi- 
cal and Surgical Journal, January, 1843.] 

The predisposing causes of plague are soon summed up. In- 
dependently of the greater susceptibility of the prime of life and ro- 
bust health, they are chiefly such as are the ordinary predisponents 
of fever, as terror, anxiety, dissipation, and exhausting exertions, 
want of rest, indulgence in the passions, whether of anger or of 
fear, &c; but, more particularly, dwelling amidst filth in confined 



PROPHYLACTIC MEASURES. 309 

and ill-ventilated rooms or situations which are subject to noxious 
vapours. 



X. PROPHYLACTIC MEASURES. 

Various means have been suggested in order to prevent the 
occurrence of plague. The chief of these are, cleanliness, free 
ventilation, sobriety in all things, a sufficiency of good and whole- 
some food, the avoiding crowded rooms, and the frequent ablution 
of the body with cold water. This last deserves much attention, 
as it has been observed, that the water-carriers of Cairo enjoy a 
most singular immunity from the disease. It is also not impro- 
bable that the lighting fires in houses, and thus effecting a perfect 
ventilation, would be attended by the most beneficial results, 
together with a judicious use of the chlorine gas, vinegar, and 
aromatics. There can also be no doubt, that it is the duty of all 
those whose sphere of life does not permit their rendering essen- 
tial service to the afflicted, to remove if it be in their power, from 
the seat of the disease, as by this means the number of victims is 
lessened, the district is less crowded, and more food and accom- 
modation are left for those remaining. 

G-alen and many others have noticed, that those who had 
issues fully discharging, did not fall victims to the disease; and 
Larrey, when with the French army in Egypt, mentions the 
curious fact before alluded to, that the plague rarely attacks 
wounded men whose wounds are in a state of plentiful suppura- 
tion ; but that as soon as the wounds are skinned over, the immu- 
nity is no longer enjoyed. On these grounds it has been sug- 
gested, that issues might be employed as a preventive against the 
disease; and certainly there is every reason to anticipate success 
from it. It has likewise been observed, that those persons whose 
trades oblige them to be covered with oil, or any other greasy 
matters, are less susceptible. This has induced many to adopt 
frictions of this kind, and with a seemingly beneficial result ; it 
may be therefore recommended to be used for such a purpose, 
especially as no injurious consequences have ever been noticed 
to follow its adoption. Inoculation, though sanguine expectations 
have been entertained upon it, has totally failed as a preventive 
against plague. In fact, the disease has never yet been satisfac- 
torily shown to be produced by this means. 

It may evidently be understood from the summary of opinions 
which have been given on the origin and progress of the disease, 
that we cannot be advocates for the system of quarantine. The 
laws and provisions made in order to enforce it, must not, how- 
ever, be passed over in silence. 



310 PLAGUE. 

We believe that were they perfect and practically well carried 
out, which they certainly are not, they would yet be, compara- 
tively speaking, useless. But they are, as now worked, not only 
useless, but most severe and vexatious incumbrances upon the 
liberty of the person ; while the lazarettos, from the situations in 
which they are placed, from the nature of the buildings them- 
selves, from the ignorance of the medical men who are appointed 
to them, tend unnecessarily to harass and annoy the individuals 
condemned to confinement in them, as also to constitute them 
places where disease may be rather originated than prevented. 
To speak of the mal-administration of the quarantine laws 
belongs, however, rather to the jurist than to the physician ; we 
therefore content ourselves by referring here to the full and com- 
plete exposures of the cruelties, hardships, absurdities, and even 
iniquities of the whole system, in the short but pregnant pam- 
phlets on Quarantine by Bowring and Holroyd. 

[From what was said in support of the contagious nature of 
plague, and in proof of its importation, it will be readily inferred 
that we regard the sanatary regulations in countries where plague 
prevails as a salutary institution, and that their abolition would 
be injurious. The effect of interior quarantines and sanatary 
police, during the last six years, has been to banish plague from 
Turkey. A recent Report on the Contagion of Plague, and Qua- 
rantine Regulations, presented to the British House of Commons, 
contains many interesting facts on this question. The Consul 
Sandison writes in 1842, "I can recollect no former period dur- 
ing which there has been such a cessation or diminution of the 
plague throughout the whole extent of the Turkish territory, as 
since the establishment of quarantines, imperfectly as they have 
been hitherto regulated." In 1812, 3,000 died daily in Constan- 
tinople, and 1500 daily in 1834, and 1836; and in Smyrna be- 
tween 30,000 and 40,000 (one-third of the population) were swept 
off] 



XI. TREATMENT. 

The treatment of plague arranges itself under the heads of 
general and local : — The general treatment to be followed is, in 
great measure, that which is ordinarily resorted to in typhus 
fever. On the first attack the prima? vise should be cleared. 
Most practitioners recommend the immediate exhibition of a 
smart purgative combined with mercury. With regard to the 
exhibition of calomel, Bulard says, that "his experience leads 
him to believe that it is always thrown up by vomiting, or evacu- 
ated by the watery motions which it causes." He also states, 
that « supported by the observations of M. Velpeau, on the ap- 



TREATMENT. 311 

plication of mercury in acute peritonitis, and by the known action 
of this remedy on the lymphatic glands, he tried mercurial fric- 
tions and blue pill ; the effects were such, that it remained doubt- 
ful whether the patients so treated suffered from the disease pro- 
duced by the medicine, or from some new phase of the disease 
itself, which might have occurred without the exhibition of mer- 
cury." With regard to the use of mercurials, Bulard asserts his 
conviction, that it is a remedy in which much faith is not to be 
placed. Sir James M'Gregor states, however, he not only used 
it as a purgative, but urged its exhibition until some soreness of 
the mouth was produced ; the consequence of which he reports 
to have been, that the skin became softer, the pulse more regular, 
the eye more clear, the tongue more moist, and that the thirst 
with the affection of the head and of the abdomen entirely disap- 
peared. The evacuations were also copious, and approached 
more nearly to their natural colour. 

The exhibition of the cathartic at the onset of the disease should 
be followed up by saline diaphoretics, and the free use of cooling 
diluents in order to promote a free perspiration. The best medi- 
cines of this class are the spirits of mindereris, the nitric Esther, 
and camphor mixture. This line of treatment is much aided by 
cold ablution. Faulkner reports its use to have been followed 
by very immediate and good effects, — the patient being soon 
relieved in all his feelings ; and, when aided by sudorifics and 
diluents, that the perspiration, which comes on, is succeeded by a 
remission from all the symptoms. He details a case reported 
to him by a Maltese practitioner, which is very illustrative of the 
good effects derivable from the sudden application of cold water. 
A man in the height of delirium, and labouring under a most 
unpromising form of the disease, ran violently out of his chamber 
and precipitated himself into the sea. From this he seemed to 
experience sudden relief. He repeated this a second time, which 
evidently restored him to a state of convalescence, from which he 
perfectly regained his usual good health. Sponging with vinegar 
has likewise been much recommended, and there can be no doubt, 
from its being a grateful operation to the patient, that it is a salu- 
tary adjunct to the general treatment. Blood-letting has had its 
advocates in plague ; but the general feeling, unless it is very 
early carried into effect, is decidedly opposed to its employment. 
A small quantity of blood taken from the arm at the very onset 
of the disease may occasionally be useful ; but its general employ- 
ment can by no means be advised, when we find Dr. White 
stating, that he used the lancet freely, but that in every case in 
which he did so death followed. 

Opium, if used with great circumspection, has been found a 
valuable remedy, by producing composure and a gentle perspira- 
tion ; but it is a medicine which must not be administered if there 



312 PLAGUE. 

be any great tendency to cerebral excitement. In the advanced 
stages, given in conjunction with the cautious exhibition of wine 
and other stimulants, it is decidedly beneficial. 

Emetics have been much recommended by some practitioners, 
who state that they not only unload the stomach and small intes- 
tines, but in great measure aid in relaxing the skin, and in bring- 
ing on a favourable state of perspiration. 

The Maltese physicians, as well as the Egyptian, are favour- 
ably disposed to the free use of vegetable acids, and particularly 
lemon juice. The nitric acid taken much diluted as a common 
drink, has been found very beneficial. It has also been used in 
the form of a bath, but without success. (Macgregor's Medical 
Sketches.) 

Frictions with warm oil have been in some cases found very 
serviceable, so much so, that Luigi of Pavia, who for twenty- 
seven years superintended the pest-house at Smyrna, states them 
to be more efficacious both as a prophylactic and as a means of 
cure than any other course. Subsequent experience does not, 
however, fully bear out the sanguine expectations of Luigi. The 
result of their employment in the French army in 1798 and 1799 
has induced the physicians who accompanied it to declare them 
to be totally inefficacious, and even to speak of them as injurious 
from the fatigue they entail on the patient. 

The local treatment for the most part is very simple, amounting 
to the application of bread and water poultices to the buboes, and 
mild ointments to the carbuncles : occasionally, if there be defi- 
cient action, some of the digestive or resinous applications maybe 
substituted. A great point to be attended to is, to obviate the 
tardy rise of the glandular swellings. Many of the French sur- 
geons speak very favourably of the use of the actual cautery and 
the potassa fusa. Bulard speaks highly of the artificial forma- 
tion of buboes by irritating the neighbouring lymphatics. He 
says, experience taught him that there is every probability of a 
recovery, when, at the commencement of the disease, carbuncles 
with broad bases made their appearance, and when the buboes 
in the groins and axillse were developed quickly, and ran on 
speedily to suppuration. In consequence of this, he inoculated 
those patients in whom these symptoms were wanting, causing 
thus artificial buboes and carbuncles ; and the majority of persons 
|o treated recovered. 

Clot Bey, in abetter to Dr. Chervin, [Brit, and For. Med. 
Rev.,) thus sums up the line of treatment to be pursued: — " The 
first symptoms are pains in the head, nausea and vomiting, injected 
eyes, staggering walk, as if from drunkenness, &c. At this period, 
emetics and diffusible stimuli may be tried. On the second or 
third day there is mental confusion, sometimes delirium; the 
tongue is dry in the centre, with red edges ; the skin hot ; there is 



TREATMENT. 313 

often pain in the epigastrium, rarely diarrhoea, buboes, and car- 
buncles. There is now actually irritation in the digestive canal, 
brain, and lymphatic glands, a^nd bleeding and cupping are em- 
ployed, with cauterization of the buboes and carbuncles to fix the 
irritation in the skin. On the fifth and sixth day petechiee and 
blue patches on the skin ; revulsions to the extremities." This 
treatment has apparently saved some patients. 

Such is a sketch of the modes of treatment which have been 
resorted to in plague ; but meagre and unsatisfactory as it is, our 
feeling in regard to them must yet be still further depressed, when 
we find a recent writer stating that, after five months' experi- 
menting with all kinds of treatment, and all modifications of it, in 
about 1000 cases, he at last arrived at the melancholy conclusion, 
that though the medicines produced their effect upon the organi- 
zation, yet the malady neither ceased nor changed. 



314 



CHAPTER V. 

YELLOW FEVER. 

[Stn. — Febris fiava, F. Americana, Typhus tropicus, Typhus icterodes, Cullen ; Pestis 
occidentalis, Vomitus niger ; Typhus of the West, Bulam Fever, Barcelona Fever, Ken- 
dal Fever ; Fievre jaune, F. icterique, F. matelotte, F. de Siam, Fr. ; Vomito negro, 
Vomit o prieto, Sp.] 

Yellow Fever is a disease which is not of nnfrequent occur- 
rence in the West Indies, in Africa, on the eastern coast of Span- 
ish America, on the southern shores of Spain, and western shores 
of America. It has been described by writers under the several 
names of Typhus icterodes, Bulam fever, Bilious remitting 
fever, Vomito negro, Vomito prieto, Endemial causus, Mai de 
Siam, &c. &c. To those commencing the investigation of yellow 
fever, it must be matter of much surprise to observe the contra- 
riety of opinion which has been entertained, both as regards its 
nature and origin. Much of this has arisen from its symptoms 
being very varying and irregular in different cases, and under 
different circumstances ; indeed, the changeableness of its pheno- 
mena renders it a matter of great difficulty to arrive at anything 
like a succinct and appropriate nosological definition. Dr. Gill- 
krest, who is the last and one of the most intelligent of the writers 
on this disease, says, that it is a fever in which « yellowness of the 
skin, partial or general, and towards the fatal termination vomit- 
ing of a black or dark brown fluid are frequent, though by no 
means, constant occurrences." (Cyc. Pract. Med., art. Yellow 
Fever.) This evidently amounts to no definition at all, and 
others which might be quoted are equally inapposite. Feeling 
the difficulty of supplying this deficiency by one that is unexcep- 
tionable, we prefer recognizing the disease only from its general 
description. In doing this, it is proposed, first, to take a view of 
the simple or more usual form in which it occurs, and then of the 
more prominent varieties which may be referred to one of three 
divisions, which we propose to designate, 1. The inflammatory ; 
2. The adynamic; and 3. The congestive, or malignant. These, 
we feel assured, after much consideration, and a careful review 
of the works of those who have enjoyed ample opportunity of 
accurately observing yellow fever as modified by climate and 
situation, will enable us to give a full and comprehensive history 
of its phenomena. 



SYMPTOMS. 315 



I. SYMPTOMS. 

The attack is for the most part, though not always, preceded 
by well-marked premonitory symptoms. These vary according 
to the peculiarities of constitution : generally speaking, however, 
for two, three, or four days, the mental energy and natural ac- 
tivity of disposition are depressed, and the spirits are low, without 
any accountably apparent reason. There are also occasionally 
faintness and debility, with slight creeping chills and nausea, pain 
in the loins, back, and extremities, some slight pain and giddiness 
in the head. The eyes, with a suffused ferrety appearance, look 
dull and watery, a heavy pain is experienced in the eyeballs and 
brow, and the vision is dim and sometimes double. There is 
often also slight confusion of thought, and the patient, though 
desirous of rest, is unable to take it, being oppressed by a drowsy 
restlessness. The taste is perverted, the appetite bad, accom- 
panied occasionally with sensation of heat of stomach, and dull 
pain in the right side ; very frequently there is a flatulent and in- 
active state of the bowels ; but this can in no way be depended 
upon as an initiatory symptom, as it not unusually occurs, that 
the opposite condition, slight diarrhoea, obtains. The same may 
be said in respect to the state of the skin; for, as Dr. Rush 
observes, the premonitory period is sometimes marked by a dis- 
position to sweat at night, or after very moderate exercise ; while 
at other times there is a sudden and complete suppression of the 
cutaneous secretion. Boyle, {On the Diseases of Jifrica^. 128,) 
who confirms this, nevertheless states that the temperature of the 
skin is always above the natural standard. The pulse varies in 
many respects ; in some cases it is small, hard, and, as it were, 
contracted ; in others soft, fluttering, or undulating, and as often 
regular as irregular ; occasionally it is full, open, and bounding. 
This series of phenomena, as before said, does not always take 
place. Occasionally it happens that persons apparently well on 
going to bed at night have awakened with a chilliness, which is 
immediately succeeded by the disease itself; others, again, are 
seized at work during the day, after having passed the previous 
night in a natural and refreshing sleep. 

Occasionally, though very rarely, the premonitory symptoms 
are accompanied by a yellowness of the skin and eyes. Such a 
state usually augurs severity in the after disease. In these cases, 
even before the fever can be properly said to have manifested 
itself, there is a vomiting of green bile ; and the early alvine eva- 
cuations, at least those which are procured from the lower bowel, 
scarcely ever fail to exhibit a very dark tar-like appearance, and 
to emit a most offensive odour. Sometimes the initiatory period 



316 



YELLOW FEVER. 



is characterized by absence of all pain, but the patient expresses 
himself as being merely inconvenienced by an indescribable sen- 
sation of general malaise. According to Dr. Rush, some of these 
symptoms frequently continue for two or three days before the 
patients are attacked by the fever ; while with some persons they 
continue throughout the time the yellow fever remains epidemic, 
without being followed by the disease. 

The commencement of the fever, which, according to Sir W. 
Pym and Dr. Smith, most frequently takes place during the night 
(according to the latter in four-fifths of the cases), is occasionally, 
though not often, attended by a slight shivering fit. The most 
usual course is, that the initial symptoms are succeeded by a state 
of general excitement, which sometimes increases to a most un- 
manageable and distressing extent, and by the accession of severe 
pain in the eyeballs and head, in the back and loins, and severe 
cramps in the calves of the legs. The position which the patient 
assumes is almost always the recumbent, when he invariably lies 
upon the back, and exhibits a constant disposition to throw the 
arms above the head. The countenance is expressive of deep- 
seated pain ; it is usually flushed, sometimes to a crimson hue, 
and occasionally swollen to so great an extent as to appear bloated 
and heavy. The eye presents appearances which furnish some 
of the chief characteristics of the disease. This organ is swollen, 
deeply injected, and moistened by tears, and has a dull or rather 
heavy drunken appearance — which peculiar expression is appa- 
rently owing to the cornea either retaining its natural, or else 
assuming a more than usually brilliant appearance, while the 
interstices between the fully injected vessels of the conjunctiva 
remain of a white colour. Sometimes these vessels are so thickly 
injected, as to give that portion of the membrane through which 
they traverse a beautiful pink colour. There is generally also 
considerable and permanent dilatation of the pupil, and the balls 
are often protruded, and seem ready to start from their sockets. 
Chisholm makes the remark, that it often happens that the right 
eye is the most considerably affected ; and that, when this is the 
case, the pain is felt chiefly in the right side of the head. The skin 
is flushed, dry, and warmer than natural, but it has not that pecu- 
liar feeling of pungency often observed in typhus fever. Warren, 
in his description of the malignant fever of Barbadoes, speaks of 
the skin being more often imbued with moisture, and that gene- 
rally there is a disposition to free perspiration : however true this 
may be in the after periods of the disease, it is decidedly not the 
case in the first stage. The pulse is accelerated, and generally 
full, soft, and compressible ; sometimes it is unusually slow; and 
cases are recorded where it has not exceeded forty-five, and, ac- 
cording to Chisholm and Physick thirty. Under these circum- 



SYMPTOMS. 317 

stances the temperature of the surface is usually unnaturally cool. 
The tongue is swollen, flattened, pointed, and coated with a white 
moist slime. Though occasionally the pain of the praecordia is 
severe during the first stage, it is yet not generally so ; in fact, the 
stomach appears free from irritation ; and vomiting, which so 
often accompanies the initial symptoms, now appears to be quite 
suspended. According to Moseley this shows that the derange- 
ments in the functions of this organ are rather owing to irritation 
than to superabundance of bile, as some have supposed. When, 
however, pain and extreme distress are experienced at this period, 
there is usually much epigastric tenderness, and spasms of a most 
violent kind take place, both in the muscles of the abdomen and 
legs; vomiting may now ensue, but what is thus voided consists 
entirely of the ingesta. The bowels appear in many instances to 
be little if at all deranged; generally, however, there is a tendency 
to costiveness ; but even under such circumstances, the motions 
which are procured by the aid of medicine, instead of being bili- 
ous, soft, or liquid, are formed healthy in character, and without 
any unpleasant fetor. The respiration is usually nervous, hurried, 
and attended by constant deep sighing ; the anxiety of breathing 
appears to keep pace with the heat of the surface. As the tem- 
perature of the skin rises, so does the respiration become more 
hurried. The intellectual functions are more or less disordered ; 
now and then coma comes on, which is usually preceded by a 
sudden and short attack of delirium. 

This first stage continues from twelve to thirteen hours ; its 
decline is marked by slight tendency to moisture on the skin, 
with a prostration of the mental and bodily powers; a state 
which Moseley has termed a collapse or metaptosis. This state 
has often been mistaken for a remission, instead of which the 
symptoms are becoming more severe. The excitement which 
has been maintained during the previous stage is superseded by 
a state of depression, characterized by collapse of the features, 
paleness of the surface generally, and a total absence of pain ; 
while at the same time there are evident signs of supervening 
irritability of the stomach, and a general tendency in the vessels 
to throw out blood. 

Before long, the second stage fairly sets in, and with a more 
formidable array of symptoms than might have been expected 
from those which were the attendants of the first stage ; the posi- 
tion of the patient is uneasy and constrained; the hands and arms 
are constantly twitching, and the legs frequently drawn up to- 
wards the abdomen. The countenance, though not so florid as 
in the previous stage, yet retains a considerable portion of colour, 
which partakes rather of a damask hue, from being blended with 
the yellow tinge of the surface, a colour which the skin now be- 
gins to assume. In the eye similar changes are perceptible ; the 



318 YELLOW FEVER. 

inflamed and injected state of the vessels begins to subside ; the 
eye thus becomes less turgid, while the conjunctiva, especially 
towards the inner canthus, begins to take on a deep yellow colour, 
which very early extends itself down the alas of the nose, and 
round the mouth. The whole expression of the countenance 
becomes altered, and in place of the excited aspect which the 
features have hitherto assumed, they are now expressive of a 
deep-seated anxiety, giving the character of a sad, depressed, 
and pensive state of mind. The moisture, which showed a dis- 
position to pervade the surface of the skin, does not fairly come 
out, but is unequally distributed in patches over the body, some 
portions maintaining their dryness and slight elevation of tempe- 
rature. 

Though in many of the milder cases the yellow colour does 
not extend generally over the surface, but is confined to the con- 
junctiva, yet most commonly, as this stage advances, the skin 
becomes of a yellow tinge, varying in hue according to circum- 
stances. If the complexion of the patient be fair, it is generally 
of a light, or what may be termed pale lemon, or even of a bright 
golden yellow, passing, as the disease advances, into a greenish- 
mottled and bruised appearance. In those who are naturally 
sallow, it assumes a deep orange or saffron colour ; in some it 
resembles a vegetable stain of a dingy yellow tint, in others it is 
not unlike that cadaverous hue which is seen on the surface of 
bodies in the first stage of putrefaction. These changed colours 
of the skin are sometimes maintained until, and even after death. 
Though this condition, if fully developed, is an almost certain 
prognostic of a fatal termination, it is by no means constantly so ; 
nor are the accompanying symptoms always severe in themselves. 
Tovvnsend observes that, in some few mild cases, the only symp- 
tom was this peculiar greenish yellow tinge, which gradually 
came out and spread entirely over the trunk and extremities, 
while the pulse, skin, and other functions, remained perfectly 
natural. [Account of the Yellow Fever, p. 151.) Dr. Harrison 
relates a similar case, in which the patient continued to walk 
about for several days, as though he was in perfect health. In 
this case the stomach and other organs regularly performed their 
duty, but black vomit suddenly came on, and death took place in 
a few hours. 

The pulse, though slightly lessened in frequency, is still full, 
but softer and less resisting: occasionally it falls below the natu- 
ral standard, but as yet it is never found to intermit. The tongue, 
though sometimes retaining its moist and dirty white coat, usually 
acquires a dry yellow crust, especially towards its root, the edges 
and tip having a clean and dry red appearance ; and in cases 
which have a fatal tendency, it is frequently tremulous on being 
protruded. The lips are dry, parched, and sometimes cracked ; 



SYMPTOMS. 319 

they look glossy, and more florid than is natural, while their 
superficial vessels show a tendency to ooze out blood and sanies. 
The stomach becomes irritable and painful, especially on pres- 
sure; the passive state which prevailed during the previous stage, 
is now very sensibly superseded by the most active functional 
disorder. Food or medicine is immediately rejected. The sen- 
sation of internal heat in this viscus is particularly distressing ■ at 
the same time there is a remarkable absence of nausea. The 
vomiting which takes place is sudden, and not accompanied by 
any continued or severe retching. Generally speaking, the mat- 
ters vomited consist only of the ingesta; sometimes, however, bile 
is likewise discharged, which, according to Dr. Stevens, is ex- 
ceedingly acrid, and frequently it inflames the biliary ducts to 
such a degree, that when the secretion ceases the surfaces adhere, 
and after death they are impervious even to the smallest probe. 
(On the Healthy and Diseased Properties of the Blood, p. 218.) 
The acrid bile must be a source of irritation to the intestinal canal, 
and is probably the cause of the severe cramps: in some cases 
such is its acrimony, that when applied to the skin, it excited in- 
flammation, and has been known even to corrode the pewter 
vessel in which it was received almost as rapidly as a strong acid. 
Flatulence is very frequent and urgent. The alvine secretions for 
the most part maintain a natural appearance, though in some 
cases they are dark-coloured and evidently bilious. The secre- 
tion of urine is much diminished ; in fact, there is an evident 
tendency to suppression, which occasionally continues for days ; 
and, should the skin be yellow, the urine partakes of the same cha- 
racter. The respiration, though sometimes remaining difficult as in 
the previous stage, is, generally speaking,unembarrassed. Deveze, 
however, says that the respiration is always difficult in this stage. 
Townsend very properly remarks, that one would suppose, by 
the indistinct manner of writers, that the respiratory functions 
were as much disturbed in this disease as in pleurisy. The only 
appearance of diseased action attending this function is, that the 
sighs are frequent, deep, and prolonged. Stevens says, that the 
breath which is exhaled has a peculiar acid odour, and that the 
degree to which this exists is, perhaps, the best criterion of the 
malignancy of the case. The intellectual functions are evidently 
deeply affected. The patient is either in a state of low muttering 
delirium, or in a comatose condition; from which, however, he 
may be roused, when he answers questions put to him pertinently, 
but soon lapses into his former condition. Sometimes there is a 
state of the most irritable and active delirium, during which he is 
particularly loquacious; in fact, his condition is not unlike, in this 
respect, that of a patient suffering under the active stage of deli- 
rium tremens. Convulsions sometimes, though rarely, take place 
during this stage of the disease. The organs of generation are 



320 YELLOW FEVER. 

very liable to inflammation, accompanied with an adhesive 
sanious discharge. This stage is besides often accompanied by 
petechia? of different sizes, occurring especially about the cheeks, 
neck, forehead, backs of hands, arms, chest, &c; sometimes inter- 
mixed with small vesicles. A miliary eruption sometimes makes 
its appearance without the admixture of petechia?. Besides these, 
there have been observed prickly heats (Moseley), boils and 
small abscesses (PFarren), or white pustules (Blane). Car- 
buncle is very rarely met with: of 7000 deaths at Cadiz, in 1800, 
there were only three instances of it. 

This stage may continue from two to six or seven days, and 
passes almost imperceptibly into that of the third, which is cha- 
racterized particularly by an aggravation of the previous symp- 
toms. The countenance becomes more collapsed and anxious ; 
the conjunctiva loses entirely its injected appearance, and passes 
from a yellow into a greenish colour, which, as Townsend re- 
marks, when contrasted with the brilliant colour of a blue or 
hazel cornea, gives an unnatural and- even grotesque appearance; 
the eye loses its full and prominent character ; the eyelids become 
swollen and discoloured, especially the under lid, which has the 
appearance of blood being extravasated through its tissue ; the 
surface of the skin generally is darker, and the discoloration 
extends over the whole body, with the exception of the feet, 
which are rarely yellowed until a short time before death. Not 
unfrequently there appear dark-coloured blotches and vibices on 
different parts of the body. There can be no doubt that these 
appearances are owing to a broken-down state of the blood, as is 
evidenced by this fluid exuding in a watery and bright-coloured 
state from the mucous lining of the nose and mouth, or, in some 
cases, from blistered surfaces, The consequence of this exuda- 
tion is, that much of it dries upon the external edges of the 
nostrils, lips, teeth, &c. The pulse becomes small and thready, 
though at times full and accelerated, yet compressible ; the tongue 
now loses its white, moist, or brown character, and presents a 
dry, inflamed, raw surface — sometimes with a dry brown fur 
covering its centre ; at times this organ has appeared to have 
been partially paralyzed, so that the speech is indistinct, and the 
voice thick, but not diminished in strength ; the mucous mem- 
branes of the eyelids and of the interior of the mouth become 
spongy and of a deep florid colour, while the lips are pale or 
livid ; the voice becomes hoarse ; the patient complains of the 
throat itself being dry ; at the same time thirst, which is a rare 
symptom in the earlier parts of the disease, becomes urgent, lead- 
ing to the inference that this symptom is owing to the local state 
of the part, and not to the general condition. It is worthy of 
remark, that yellow fever is not attended by those disagreeable 
cadaverous smells so often observed in other fevers. As the dis- 



SYMPTOMS. 321 

ease advances, the pain in the region of the stomach increases, 
and the least pressure adds to the patient's agony. An eructation 
of wind, or swallowing fluids hot or cold, causes an involuntary 
drawing up of the legs. 

This state is followed by vomiting of a grumous-looking fluid, 
which has been technically called the black vomit — in fact, it has 
in some countries given the name to the disorder : thus, in Spain, 
from the occurrence of this peculiar symptom, it is called the 
vomit o prieto, or negro. This vomiting does not, however, 
always occur, even though the nausea, and other evidences of 
stomach affection, may be present. The alvine discharges often 
retain, even to the last, a healthy appearance, and are totally 
devoid of nauseating smell: sometimes, towards the end of this 
stage, while the dejections are evidently composed of the same 
grumous exudation as the black vomit, they often assume the 
natural appearance, even when the other symptoms indicate an 
aggravation of the disease. As this stage advances, the anxiety 
and restlessness increase to a most distressing extent, which, with 
loss of sleep, portend danger. The intellect is not so much 
affected as might have been expected ; though there may be 
excitement and slight confusion, there cannot be said to be de- 
lirium. The respiration is hurried, noisy, and evidently labori- 
ous, the muscles of the neck and chest being violently brought 
into action to support the effort required. The whole appearance 
of the patient is that of exhaustion. The surface and extremities 
become very cold, and covered with a general clammy perspira- 
tion, excepting over the hypochondriac regions, where the tem- 
perature is still maintained. Tremor and subsultus sometimes, 
though not very commonly, ensue, and occasionally there is stra- 
bismus. Townsend says, however, that more frequently, at this 
late period of the disease, the eye and countenance remaining 
calm and perfectly natural in their expression, and the intellectual 
functions unclouded, the patient lies tranquil and unconscious of 
danger, and expires without a struggle. Dr. Rush says, the last 
hours of life in some were marked with great pain and strong 
convulsions, but in many more death seemed to insinuate itself 
into the system with all the gentleness of natural sleep. To the 
experienced eye, however, the general expression, the unsteady 
small pulse, the clammy perspiration of the forehead, &c., too 
truly betray the alarming condition of the patient. In some very 
aggravated cases a curious state has sometimes occurred, not- 
withstanding the depression of the powers — the patient rises from 
his bed, and in a staggering manner walks about, and really 
effects feats of very considerable exertion, sometimes even with 
the appearance of so little weakness that, to bystanders, it scarcely 
appears the patient is labouring under disease. This form of yel- 
low fever has been called the cold walking fever. 
21 



322 YELLOW FEVER. 

Such may be esteemed to be the more ordinary symptoms of 
yellow fever. There are, however, many deviations from these, 
and which, from occurring in different years and at different 
places, have given origin to the contradictory statements and 
opinions as to the very nature of the disease itself. The varia- 
tions are, however, to be regarded as merely those departures 
from its more usual course to which it, in common with other 
forms of fever, is liable. These we shall endeavour to point out 
under one of the three following divisions: — The inflammatory, 
the adynamic, and the malignant. 

1. The inflammatory form commences with initial symptoms 
characterized by more weakness, and faintness, and nausea, 
which, after a period of ten or twelve hours, are followed by 
sudden development of excessive arterial reaction, more espe- 
cially observed in the carotid and temporal arteries ; the pulse is 
quick, generally full, tense, and strong ; there are much anxiety 
and constriction of the prsecordia, with hurried breathing, and 
desire for cool air; while the nausea increases, and terminates in 
retching or vomiting ; the face is frequently flushed ; the conjunc- 
tiva deeply injected, and gives the countenance a heavy dull 
expression ; the tongue is coated with a yellowish-white fur; the 
thirst is urgent ; the skin dry and parched, though occasionally 
moist; severe snooting pains are felt in the head, loins, and ex- 
tremities; the bowels are confined; and the urine scanty and 
high coloured. 

This stage lasts from twenty-four to sixty hours, and is gradu- 
ally converted into the second, in which many of the symptoms 
are gradually subdued. The heat of skin completely passes off, 
and is succeeded by chilliness, and the pulse becomes more slow 
and soft. Though these appearances may appear favourable, 
there arise too many other indications of a contrary tendency. 
The eyes look glassy ; there is confusion, and occasionally low 
muttering delirium; the pain and sickness of stomach become 
more urgent, and the vomiting more frequent; the skin is imbued 
with a clammy moisture; the tongue is dry, covered with a brown 
fur, beneath which its surface is rough and cracked ; the urine is 
in great measure suppressed, and the little that may be secreted 
is of a brownish-yellow colour. 

After this state of things has continued with varying intensity 
from twelve to thirty hours, a change ensues, which is the com- 
mencement of the third stage : the pulse becomes rapid and in- 
termitting, the pain accompanying the vomiting is distressing in 
the extreme, and the matters vomited are of a dark colour, not 
unlike coffee grounds ; the tongue is black ; the lips and mouth 
coated with a black sordes ; cold clammy sweats pervade the sur- 
face : and the whole skin becomes yellow, first commencing in 



SYMPTOMS. 323 

discoloration about the mouth, nose, and temples. This state, 
when fully confirmed, is the commencement of a fatal termina- 
tion ; an event which is preceded by delirium, laborious respira- 
tion, convulsive sighing, subsultus tendinum, faltering voice, 
bloody exudations from the mucous surfaces of the nose and 
mouth, petechia?, frequent vomiting of black fluid, burning heat 
of the stomach, hiccough, and eventually coma. 

This form of the disease varies greatly in intensity and in its 
period of fatality ; occasionally the symptoms are so slight, that, 
though presenting all the characters of the inflammatory variety, 
convalescence is established without their having assumed any 
peculiar urgency ; at other times they set in with such determined 
violence that the patient sinks under their influence in the course 
of twenty-four hours: generally, however, in fatal cases, the 
period is from three to five days. Its victims are usually of a full 
plethoric habit, such as might be called of a strong healthy con- 
stitution. 

2. The adynamic variety, on the contrary, usually occurs in 
those whose frame is expressive of deficient animal vigour, and in 
whom the circulating system is for the most part depressed. The 
initial symptoms, which are often prolonged for days, are usually 
a varying degree of nausea and faintness, slight headache and 
confusion, with occasionally dimness of vision. On the attack 
setting in, there is sensation of great oppression, with severe 
headache and excruciating pain in the loins, legs, and feet, and, 
as in the former variety, tenderness in the region of the stomach, 
accompanied by nausea and vomiting, urgent thirst, and costive 
bowels. Unlike the inflammatory, however, the skin is usually 
soft and bedewed with a clammy softness; and, as Dr. Craigie 
describes it, "a fixed sensation of cold, pervading the person 
deeply, and rarely interrupted with flushing and other marks 
of heat, is slowly succeeded by a sensation of heat, which, though 
pungent at the epigastric region, under the arms, and inside the 
thighs, is seldom strong or high on the exterior of the person or 
the mucous surfaces." The tongue is white and moist, the pulse 
small and weak, the eye of a dingy colour, and languid in its 
movements, the whole expression of the countenance partaking 
of the same character. This state, which continues often for 
some hours, according to the severity of the attack, is succeeded 
by one in which the above symptoms become aggravated, excru- 
ciating pain of the stomach, vomiting, general torpor, and low 
muttering delirium supervening. This state is followed by coma, 
during which the skin, now damp and flaccid, assumes an olive 
colour, and becomes spotted with livid vibices; the conjunctiva 
of a dirty yellow colour, and the countenance expressive of the 
fatal termination, which is usually accelerated by copious hemor- 
rhage from the nose, mouth, and intestines— the black matter 



324 



YELLOW FEVER. 



which is now vomited, as well as the fecal discharges, being 
mingled with the blood. This form of disease usually proves 
fatal within four or five days. 

3. The malignant or congestive form of yellow fever is par- 
ticularly characterized by early oppression, and the almost total 
absence of any symptoms of reaction. From the commencement 
the patient makes but little complaint, and with the exception of 
pain in the region of the stomach, expresses no particular uneasi- 
ness. He lies quiet, and though there is very considerable mus- 
cular power remaining, makes no effort to move. He is for the 
most part taciturn, and might almost be supposed to be asleep, 
were it not for the eyes which are wide open : sometimes this 
state is slightly interfered with by transient delirium. The eye 
itself is of a dull red, and has a drunken, dull, agitated stare. 
The countenance from the very first is indicative of the malig- 
nancy of the disease ; it is ash-coloured and mottled, has a con- 
fused sullen expression, and altogether presents a shrunk and 
deadly aspect. The skin is generally not elevated in tempera- 
ture, but for the most part slightly chilled ; which, as the disease 
advances, becomes more marked, and gives to the finger while 
touching it a most repulsive sensation. It early assumes a slight 
livid colour, which rapidly increases to a deep leaden hue at the 
point of the fingers, tips of the ears, &c, and in many parts 
patches of a deeper and more putrid character show themselves. 
The pulse is small, intermitting, and eventually almost impercep- 
tible. There is throughout the attack not the slightest evidence 
of any vascular excitement. The tongue is swollen, smooth on 
its surface, of a red or livid colour, and covered here and there 
with foul white patches. The stools, if passed, are white, and 
the urine is almost entirely suppressed. The respiration is labori- 
ous, and the black vomiting, accompanied by hiccough, sets in 
early. Few who are thus attacked recover; many die in the 
first twenty-four hours ; others go on to the third day. 

[The following is a summary of the symptoms observed by 
Dr. Louis, during the Gibraltar epidemic of 1828.* Dr. L. gives, 
first, the symptoms met with in the fatal cases; secondly, those 
of the severe cases which recovered ; and lastly, those presented 
in the mild cases. 

* [In 1828, an epidemic of yellow fever occurred at Gibraltar. The French 
government sent a commission, composed of Drs. Gendrin, Louis, and Trous- 
seau, to investigate it. The commission arrived there thirty-three days before 
the termination of the epidemic. Dr. Louis drew up an elaborate report, which 
was translated by Dr. G. C. Shattuck, of Boston, and published in 1839. The 
original has since been inserted in the second volume of the Memoirs of the 
Medical Society of Observation of Paris. It should be borne in mind that the 
work professedly records only the observations made in a single epidemic, and 
that, too, at an advanced period.] 



SYMPTOMS. 325 

1. Fatal cases. — These commenced with an intense headache, 
accompanied with chills, shivering, pain in the limbs, and, soon 
after, pain in the back. A heat, rarely intense, succeeded to the 
chills, and was sometimes followed by perspiration. At the same 
time the countenance became red and animated, and in some 
cases swollen. The eyes were red, glistening, suffused, and 
patients often complained of a sensation of smarting in them. 
The thirst was intense, the anorexia complete. Pain at the epi- 
gastrium usually came on in fifteen or twenty hours from the 
commencement of the disease. It was generally inconsiderable, 
and very few patients complained of severe or acute pain. With 
the epigastric pain came nausea and vomiting, excited by drinks 
and purgatives in several cases, spontaneous in others. The de- 
jections were infrequent, that is, where no laxatives had been 
administered. The abdomen preserved its form, was supple and 
not painful to the touch, except in the epigastric region. The 
sleep was inconsiderable, some patients were restless, and in 
some there was a good deal of jactitation during the night. The 
smaller number experienced, as early as the third day, a real 
anxiety, could not remain in any posture, and in some cases there 
was delirium; but this symptom did not usually come on till the 
last day of life, and for this reason is rather to be considered as 
belonging to the agony than the disease. Otherwise, with few 
exceptions, there was neither prostration nor stupor. The pulse 
was moderately accelerated, regular, generally bearing relation to 
the degree of heat, which was generally slight. The skin of the 
thorax was injected in some cases. This redness and that of the 
eyes diminished towards the middle period of the disease, or a 
little later, and new symptoms appeared. To the injection of the 
integuments of the chest there succeeded a slight yellow tint of 
that part, and the eyes were of the same colour. When this 
colour appeared thirty-six or forty-eight hours before death, it 
became rapidly brighter, so as to be of some intensity at the time 
of the fatal termination. In other cases where it came on only 
just before death, it was slight at the autopsy, and commonly 
limited to the trunk. About this period, or a little later, the mat- 
ter vomited, from being of a yellow colour, became brown or 
black, and the dejections blackish or black. At this period of 
the disease, the uncomfortable feelings and the anxiety continued 
during different lengths of time and in different degrees; the 
strength diminished, the temperature fell, so that the limbs were 
cold before the agony, and in a certain number of cases there 
was suppression of urine. Yellow fever resembles other dan- 
gerous febrile diseases in an occasional mildness of external 
aspect even in fatal cases; the slightness, as Dr. Louis observes, 
of the fever, and of the pains wherever seated, the absence of 
agitation and delirium, and the little diminution of strength im- 



326 YELLOW FEVER. 

pressing on the disease a character of mildness calculated to 
deceive at once the patients, their attendants, and the physician. 
It was under this form of disease that patients died without taking 
to their beds, on foot, as it was expressed by their friends. The 
severity of the symptoms did not always correspond with that of 
the lesions. 

2. Severe cases in patients who recovered. — The early symp- 
toms differed in degree only from those in the fatal cases. In 
some subjects the stools became black, and in a few, and these 
mostly children, the brown or black vomit occurred. In a great 
many cases there was no yellowness, and in the majority of cases 
where it was found it came on from the fourth to the sixth day 
of the disease. The extreme restlessness, the jactitation which 
took place in those who died was not met with in any of the 
cases now under consideration. Towards the fifth day, the symp- 
toms became less severe, the skin cooler, the pulse calm, the epi- 
gastric pain diminished or totally disappeared, the thirst was less, 
the appetite returned, and convalescence commenced. 

3. Mild cases. — These began with the usual symptoms very 
slight in degree. In the progress of the complaint the epigastric 
pains were rare, and. so too were the vomitings, which were 
almost never spontaneous, and which in no case were of a 
brownish colour. So slight was the diminution of strength, that 
the patients either did not keep their beds at all, or were there for 
half a day only, thus, to use their own expression, going through 
the disease on foot.* In several of these cases the febrile symp- 
toms were very slight, continuing only during twenty-four or 
thirty-six hours: yet these persons were exempt from any other 
disease in the course of the epidemic, though exposed to all the 
causes which could have produced in them the yellow fever, and 
it was likewise remarked that persons who had been thus slightly 
affected in the epidemic of 1804 passed uninjured through the 
epidemics of 1818, 1824, and 1828. This mild form was princi- 
pally observed in children. 

Dr. Ashbel Smith, of Texas, published, in 1839, a very 
graphic account of an epidemic of yellow fever which had just 

* [These cases Dr. Rush used to call the "walk about" cases, in which the 
patients scarcely feel or acknowledge that they are ill, refuse to go to bed, and 
are unwilling to be subjected to treatment; with hardly an exception they sink 
and die promptly. Dr. Dickson, of Charleston, mentions the instance of a stout, 
fresh New Englander, an engineer of one of the steamboats, who retained, to the 
moment of his death, his uncommon muscular strength, and his florid, ruddy 
complexion. "It was singular," he says, " to see him, indeed, going about from 
room to room, and into the piazza, when, from the urgent irritability of his 
stomach, he was obliged to carry with him a vessel to receive the black vomit, 
which he threw up frequently and in large quantities."**] 

o [Practice of Physic, vol. i., p. 351.] 



SYMPTOMS. 327 

occurred at Galveston, in that state. * Between Dr. Smith's de- 
scription and that of Louis, there is the closest resemblance. 
There were first pains in the limbs, some sickness at stomach, 
chills not amounting to complete rigor, and some diminution of 
the sensibility of the extremities. In a variable period, ranging 
from two or three minutes to a few hours, there succeeded pain 
in the forehead and eyes, pains in the loins, great restlessness, 
bloodshot eyes, flushed face, hot and dry skin, and full and fre- 
quent pulse ; whilst the pains in the limbs and the sickness of the 
stomach, which were present at first, still continued. The tongue 
was moist, and sometimes furred and swollen, but not unfre- 
quently of a healthy aspect. The thirst was often moderate, in 
some cases considerable, never intense ; the epigastrium was 
slightly sensible on pressure in some cases, in others quite free 
from pain. The mental operations were generally coherent, but 
sluggish. The restlessness did not consist in jactitation, but in a 
disposition to rise from bed and walk about. A diminution of 
pain and febrile excitement very generally takes place from eight 
or ten to twenty-four hours after the invasion. If the disease 
proceed to a favourable termination, this abatement is progres- 
sive, and convalescence takes place at a period varying from the 
third to the fifth or seventh day, or in one case the fifteenth day. 

Dr. Imray, of Dominica, has recently given an account of the 
epidemic in that island in 1843.t He says: — The commence- 
ment of the attack was without rigors, seldom even with chilli- 
ness, and usually very sudden, with great prostration of strength, 
intense lumbar pains, extending along the thighs, extreme rest- 
lessness and anxiety. The headache was of a peculiar character, 
differing from this symptom as usually met with in the common 
fevers of this country. The pain, generally very severe, was 
confined, in most cases, to the temples and occiput ; sometimes 
the forehead was affected, but pain was rarely experienced in the 
coronal region. On the second, third, or fourth day came the 
subsidence of all the acute symptoms, freedom from pain, cool 
skin, slow pulse, yellowness of surface, followed in a longer or 
shorter period by bleeding from the mucous surfaces, the deadly 
black vomit, or cerebral and nervous symptoms, equally certain 
forerunners of death. In every instance there was yellowness of 
the skin, the yellow tinge appearing about the second day.] 

Such are the more ordinary forms which yellow fever as- 

* [An Account of the Yellow Fever which appeared in the city of Galveston, 
Republic of Texas, in the autumn of 1839, with Cases and Dissections. By 
Ashbei Smith, M. D., A. M., Ex-Surgeon-General of the Texian Army. Galves- 
ton, Texas, 1839: 8vo., pp. 78.] 

f [Observations on the Nature, Causes, and Treatment of Yellow Fever, as it 
prevailed in the Island in 1841. By Johk Imrat, M.D., of Dominica. — Ed. Med. 
and Surg. Journ., vol. Ixiv., No. 165, Oct., 1845, p. 321.] 



328 



YELLOW FEVER. 



sumes, each of which presents occasional variations, but they 
are not accompanied by such marked characters as to require 
particular description. One variety, however, may be noticed, as 
it has by many writers been considered a separate disease ; it has 
been described under the names of the African endemic fever, 
the climate or seasoning fever, &c. Dr. Stevens, who very de- 
cidedly advocates the view of its being a distinct disease, describes 
it as differing from yellow fever in being indigenous, and in not 
being contagious, as he esteems the latter to be ; that it is only 
met with as an epidemic during the hot months, when the ther- 
mometer is upwards of 88° during the day, and at least 80° during 
the night. It occurs generally in dry situations, very seldom in 
swampy districts, and only in solitary cases, except in those 
localities where there is an accumulation of unseasoned strangers, 
exposed to the action of a burning sun. He further states this 
disease to be confined to the whites, and almost entirely to those 
who have arrived lately from northern countries ; while the Afri- 
can typhus, as he terms yellow fever, appears in the West India 
islands in every locality and at all seasons of the year. It is not 
confined either to the whites or to those who have lately arrived ; 
he has known it just as fatal to the negroes and Creoles, who have 
never been out of the tropics, and equally mortal in the coolest 
weather as in the hottest months. He says it can easily be dis- 
tinguished from yellow fever, from there being no marked pre- 
monitory symptoms, no cold stage in the commencement, no 
foulness of the tongue, no sickness or irritation in the stomach, 
at least for the first twelve hours after the attack, no derangement 
in the biliary organs, no spasms in the gastrocnemii muscles. All 
the secretions are diminished, but there is no redness in the urine : 
the pulse in the first stage is not only incompressible, but the 
artery at the wrist is distended to a degree which is never met 
with in any other disease. He likewise states that, though in the 
climate fever the blood is diseased, it is not unnaturally dark in 
colour before the attack, which he states to be the case in yellow 
fever. Notwithstanding these strongly expressed opinions, it 
does not appear from other evidence that there is that dissimi- 
larity which should entitle the so-called endemic disease to be 
separated from yellow fever. It appears from the observations 
of many who have had ample opportunity of satisfying them- 
selves upon this point, that they are essentially one disease, only 
occurring under certain modifications. It is not a little singular 
that Boyle, who advocates the view of their being separate dis- 
eases, after describing at large the endemic fever, says, that the 
general character and symptoms of the epidemic, i. e., the yellow 
fever, bear so strong a similarity to those of the endemic fever, 
that it seems to be only necessary to refer to the description of 
the latter. We are inclined to believe that the climate fever is 



SYMPTOMS. 329 

the ordinary fever of the country; and that, when it assumes an 
epidemic severity, it acquires those characters which are peculiar 
to yellow fever [See p. 84.] 

The nature and origin of the fluid discharged from the stomach, 
so characteristic of this disease, and which has been technically 
called black vomit, have been very differently viewed by writers. 
On the first appearance of this discharge it has a turbid reddish- 
brown appearance, is insipid and perfectly inodorous, and settles 
at the bottom of any fluid with which it may have been mixed 
in the stomach. It presents an appearance not unlike coffee 
grounds, and is so mingled with mucus, as to be ropy and glutin- 
ous to the feel; sometimes it is intermixed with small streaks of 
blood. Examined by a microscope, this coffee-ground-looking mat- 
ter appears to be inorganic in its nature ; when strained and dried 
on paper, to which it will adhere, it retains its dark brown and 
red colour, and exhibits the appearance of a powder, not unlike 
minute scales of smoky mica, both as regards colour and feel. 
From various experiments Dr. Cathrall concludes that the 
black vomit, besides a considerable proportion of water tinc- 
tured with resinous and mucilaginous substances, contains a 
predominant acid, which is neither the carbonic, phosphoric, nor 
sulphuric, but which, he hints, may be the muriatic. It likewise 
appears from his experiments, that when applied to the most 
sensible parts of the body, it produces little or no effect ; that 
large quantities of it may pass through the stomach and bowels 
of animals, without apparently disturbing digestion or affecting 
the health ; and that an atmosphere highly impregnated with its 
exhalation, does not produce fever under apparently the most 
favourable circumstances. From these facts he infers, that the 
speedy death which ensues on this discharge is not from any 
destructive effect of this matter on the stomach and bowels, but 
most likely from the degree of direct and indirect debility which 
precedes and accompanies it. {New York Repository, 1800.) 
With regard to the nature of this peculiar fluid, some state it to 
be vitiated and putrid bile ; others, a mixture of blood and bile ; 
some, that it is the sphacelated mucous coat of the stomach dis- 
solved in a morbid secretion of this organ ; others conceive it to 
be a morbid secretion from the liver. The view of Dr. Fordyce 
appears to be the correct one, viz., that it is identical with the 
incrustation on the tongue, gums, lips, &c, in violent fevers, and 
that, probably, it is an exudation from, and is formed upon the 
surface of the stomach, and perhaps of the duodenum, or even 
the beginning of the jejunum. It is probably nothing but broken- 
down blood, which oozes from the secreting surface of the mu- 
cous membrane in place of its natural and proper secretion. The 
force of the exertion in vomiting often occasions a considerable 



330 YELLOW FEVER. 

quantity of bile to be secreted, which, being thrown back into 
the stomach, is brought up with the dark brown matter. When 
this happens it gives to the fluid the taste and appearance of bile. 
[The following interesting remarks on the nature of black 
vomit by Dr. Josiah C. Nott, of Mobile, will be found in an 
instructive paper contributed by him to the American Journal of 
the Medical Sciences, for April, 1845. <* It cannot, I think, be a 
secretion,* he says, " because it is most commonly seen in little 
particles or masses of various magnitude which could not pass 
through a secreting capillary, and my own opinion is that the 
black vomit is blood, exhaled in its natural state from the capil- 
laries of the stomach, intestines, and even the bladder, and 
changed black by the secretions with which it comes in contact ; 
this chemical change, my facts go to show, is produced by one or 
more acids. With the assistance of my friend, Dr. P. H. Lewis, 
I have tested the black vomit in a considerable number of cases 
this summer, (1844,) and in every instance I have found it to be 
acid ; when ejected from the stomach during life, it invariably 
turned litmus paper red, and the aqueous portion of that which 
was taken from the stomach after death and filtered, in several 
cases effervesced strongly with carbonates. The aqueous portion 
thus filtered, differed in colour; in some it was perfectly limpid 
like water; in one of a light green colour like dilute bile with an 
acid added, and in others, it was of a deep brandy or rum colour; 
which appearance was no doubt given by a small admixture of 
blood. The secretions of the stomach in yellow fever are often 
excessively irritating, and this property is probably attributable 
to the presence of acid ; the patient often complains, in the black 
vomit stage, of a burning or scalding sensation in the stomach, 
which is immediately relieved by throwing off its contents. The 
patient, too, often complains of the black vomit scalding the oeso- 
phagus, which, after death, is usually found more or less denuded 
of its epithelium. The acridity of this secretion may possibly 
account for many of the morbid changes in the stomach and oeso- 
phagus. A morbid secretion of tears will scald the cheek ; mucus 
from the nose inflame the lip ; morbid secretions from the bowels 
excoriate the anus; morbid bile irritates the stomach and bowels, 
&c, and we know that the gastric juice will often corrode the 
stomach in a short time after the extinction of life. The next 
step was to ascertain whether acids would with blood produce a 
compound with the characters of black vomit. I accordingly 
took a few drachms of blood from the heart of a patient dead 
of yellow fever, and added to it four or five drops of muriatic 
acid, diluted with a drachm or two of water, and shook them well 
together ; the black colour was produced instantly. The same 
experiment was tried repeatedly on the blood of yellow fever 
patients, and on that drawn from a patient with pleurisy by cups, 



SYMPTOMS, 331 

and the effect was invariably the same. Any one wishing to form 
a correct idea of black vomit, has only to treat blood in this way, 
and add a little gum water or flaxseed tea to represent the mucus 
of the stomach, and his curiosity will be gratified; no one can tell 
the artificial from the genuine black vomit. Sometimes the blood, 
after passing through the exhalents minutely divided, is coagu- 
lated in little particles, which, when blackened, present the ap- 
pearance of coffee grounds; this appearance is difficult to imitate 
in the artificial black vomit, because we cannot readily produce 
these small coagula. I presume other acids will produce the 
same effect as the muriatic and crystalized acetic [citric?], the 
only acids which I experimented with. We have then established 
two important links in the chain ; the black vomit in the yellow 
fever of 1844 was acid, and acids turn the blood black. When- 
ever, in yellow fever, blood is exhaled from the mucous coat of 
the stomach or bowels in small quantity, a quantity proportion- 
ate to the secretions of these surfaces, it is [according to my 
observations) invariably found black, and the aqueous portion 
limpid or clear green. If there be a slight excess of blood (more 
than enough to neutralize the acid) instead of black, we find a 
nut brown, a chocolate or reddish matter, and the watery portion, 
when filtered, of a rum, brandy, or red colour. If the hemor- 
rhage be great, we have (as I have often seen vomited) a fluid 
with all the characters of blood, either with or without a mixture 
of black vomit. I have often seen a tablespoonful or two of the 
< coffee grounds' at the bottom of the basin with a pint or more 
of pure blood ; this I have several times pointed out to others. 
In the case of Mr. Covert, whom I saw with Dr. Mordecai, I had 
presented to me at one time three basins, each containing a full 
pint of blood with the black vomit intermixed and lying at the 
bottom. As an additional proof that the black vomit is blood, 
changed by the secretions of the stomach and bowels, I will state 
that I have never seen red blood, in yellow fever, tangled with 
mucus; when thus mixed it is always black. This exhalation 
of blood and chemical change is by no means peculiar to the 
stomach, but evidently takes place over the whole mucous sur- 
face of the canal. I could cite many facts to prove this, and 
abundant evidence will be found in the work of M. Louis. I 
have frequently seen black matter, like black vomit, in the urine, 
and it is formed no doubt in the same way, by blood combined 
with an acid in the urine, or in the mucus of the bladder. Dr. 
Lewis and myself are at this moment attending a medical gen- 
tleman (Dr. Fletcher) in whom this formation has been going 
on for some days, and at the same time the patient is throwing 
up black vomit and purging pure blood from the bowels. There 
are many facts connected with other diseases, and analogies 
which would throw light upon this interesting subject, but I must 



332 YELLOW FEVER. 

touch them lightly for want of space. Blood which is vomited 
or purged in other diseases, after being retained in the alimentary 
canal (in contact with the secretions) is usually very dark, and 
not unfrequently black. In haemoptysis the blood, on the con- 
trary, is usually florid, and we are told by many that in the one 
case the blood is venous, and in the other arterial ; but the blood 
in the two cases is doubtless exhaled from the same set of vessels, 
and the difference can only be accounted for by the chemical 
action of the gastro-intestinal secretions. We know that in the 
vomiting of pregnancy, little specks or streaks of blood are fre- 
quently thrown up, and when females in this condition are at- 
tacked with fever of any kind, accompanied with excessive and 
protracted vomiting, small specks or streaks of black matter, like 
broken-up butterfly wings, are frequently seen. This kind of 
vomit is the usual precursor of genuine black vomit, and has the 
same explanation. Every experienced physician must have seen 
this, and my friend Dr. Crawford yesterday related to me a very 
interesting case of this kind attended by himself and Dr. Morde- 
cai ; the patient (the wife of a distinguished lawyer) during the 
month of December last, ill of a protracted fever, possessing no 
other symptoms of yellow fever, and at a time and place where 
this disease was not prevailing, threw up black matter profusely, 
which could not be distinguished from the black vomit of yellow 
fever. We all know how abundant is the formation of acid in 
delicate females when pregnant. A very small quantity of blood 
oozing gradually in a minutely divided form, and mingling slowly 
with the secretions of the mucous membrane of the stomach and 
bowels, will make a large quantity of black vomit. Judging 
from my experiments, I should think a tablespoonful would 
make a pint. A moderate quantity of bile may exist in the 
black vomit without being perceived ; this I proved by adding 
bile to the artificial black vomit, and by filtering the genuine 
black vomit, the aqueous part of which in one case was green, 
and this colour, I presume, was attributable to a small admixture 
of bile. Authors have gone into laboured descriptions of the 
varieties of black vomit, but my belief is, and the preceding facts 
go to prove that they are essentially the same, blood, — acids, 
mucus, and aqueous fluid, mixed in various proportions. Give 
me blood, muriatic (or, I presume, any other acid) and gum 
water, and I will make it to suit the notions of the most fastidi- 
ous pathologist ; perfectly black, brown, reddish, &c." 

Of this constant phenomenon — by some regarded as pathog-. 
nomonic — Dr. Dickson says, " Though occurring so familiarly in 
yellow fever as to give it a name in one language at least, it is 
by no means exclusively or specifically a symptom in that disease 
only, and of course cannot be regarded as a diagnostic. I have 
myself met with it in several cases of bilious remittent, and in 



SYMPTOMS. 333 

gastritis and enteritis; in one case of varioloid, occurring in winter; 
in catarrhal fever once in March ; twice in dropsy, and once in 
the familiar vomitings of pregnancy. It attends puerperal fever 
occasionally, and always, I believe, follows rupture of the ute- 
rus [?]. Dr. P. G. Prideau, whose professional experience has 
seldom been equaled, and whose authority upon any point of 
fact is indisputable, assured me that he had repeatedly known 
it to take place among the easy vomitings of pregnant women 
without unpleasant results; and that he had once witnessed its 
spontaneous occurrence in a youth from mere fatigue, ceasing 
readily, and leaving him quite well."*] 

It does not appear that yeilow fever is particularly compli- 
cated or altered in its character by the supervention of another 
disease, or by its occurring when some other disease is present. 
Amiel says, during the time it raged as an epidemic at Gibraltar, 
no other acute maladies prevailed; it seemed to have the pecu- 
liarity of modifying or completely changing the nature of the 
acute as well as of the chronic diseases. Dr. Smith and others 
state, that persons labouring under other diseases at the time they 
were attacked with yellow fever, fell victims to it, and that this 
fatality appears to have been particularly marked in females in a 
state of pregnancy. Sir William Pym makes the curious ob- 
servation, that several of those who were attacked had pulmo- 
nary complaints, and that in some cases these affections appeared 
to be cured in consequence. 

Yellow fever may terminate in complete recovery, or the reco- 
very may be retarded by chronic organic affections ; it may also 
prove fatal. Though in many of the slighter cases convalescence 
takes place early and perfectly, yet there is very frequently the 
most decided evidence of organic lesions. The organs most 
usually diseased are the stomach and liver. The lungs, spleen 
and nervous system have also been observed to participate. 
Some writers state that it occasionally terminates in fits of ague. 
Amiel says that the rapid progress and the short duration of this 
disease leave no time for visceral obstructions to be formed; 
and the only sequela? which he observed were excessive weak- 
ness, an impaired state of the digestive organs, and, as a neces- 
sary consequence, a protracted and tedious convalescence. [The 
infrequency of chronic disease after yellow fever is satisfactorily 
shown by Dr. Catel, of St. Pierre,* in his account of the Mar- 
tinique epidemic of 1838-39. Of more than one thousand 
patients discharged from the hospital, not one presented any 
evidence of disease likely to become chronic] 

* [Dicksok's Practice of Physic, vol. i. p. 355. Charleston, S. C, 1845.] 



334 



YELLOW FEVER. 



II. ANATOMICAL CHARACTERS. 



The morbid appearances observed in fatal cases of yellow 
fever are very various. The external appearance of the body 
retains, after death, much the same dusky yellow, gray and mot- 
tled colour, which has been observed during life. Such parts as 
are pending not unfrequently become livid, while the extremities 
and scrotum in males are generally of a brownish-black. A line 
of a pale cast of yellow, from the nose to the pubis, has been 
sometimes observed. The generally darkened or discoloured 
condition of the integuments has induced many to suppose that 
the body is peculiarly liable to undergo a rapid decomposition ; 
this, however, appears to be no more the case than it is in plague. 
The discolorations which are apparent on the surface, do not 
appear necessarily to involve any other tissue than that of the 
skin ; for frequently the cellular membrane immediately below, 
though said to be usually diseased, is often not in the least dis- 
coloured ; occasionally, however, it is a little yellow. The mus- 
cular tissue is often darkened, softened, or even broken down; in 
some cases an uniform venous infiltration into the cellular tissue 
of the muscles has been observed. 

[In those cases examined by Louis at Gibraltar, there was ob- 
servable great cadaveric rigidity, and in some the muscular pro- 
minences were as well marked as they could have been during 
life when the muscles were in a state of strong contraction. 
The skin was yellow in all except three, and when the yellow- 
ness was not well marked it was more so on the trunk and head 
than on the limbs. The muscles had their natural colour, firm- 
ness, and cohesion. In one case the superficial muscles of the 
calves and hams were infiltrated with blood. That the disposi- 
tion to hemorrhage was not great is shown by the fact that in 
one only of twenty-three cases was there a slight exhalation of 
blood in the subcutaneous cellular tissue and in the superficial 
muscles. Dr. Imray states that the yellow livid colour of the 
body became deepened after death, and that decomposition ad- 
vanced rapidly. Dr. Ashbel Smith speaks of the peculiar yel- 
low cadaveric hue as pathognomonic] 

On examining the head, the surface of the dura mater is found 
studded with dark-coloured spots, with patches of lymph here 
and there ; there is usually infiltration of yellowish serosity, to a 
greater or less extent, under the arachnoid, with congestion in 
the veins and sinuses, though in some cases this is not very re- 
markable. The substance of the brain is firm and more vascular 
than natural, but in some very protracted cases it becomes soft- 



ANATOMICAL CHARACTERS. 335 

ened. The choroid plexus is much distended, and instead of pre- 
senting its beautiful appearance looks like a clot of blood. The 
ventricles sometimes contain an excess of fluid. With regard to 
lesions in the vertebral column, Dr. Gillkrest says, that in exa- 
minations conducted on a small scale by a French medical com- 
mission sent to Barcelona during the epidemic of 1821, erroneous 
views had been hastily adopted as to the spine being the fons 
and origo mali in yellow fever; but subsequently these opinions 
were admitted to have been entirely, or in part, erroneous, 
Magendie having shown that there is in the healthy state a 
certain quantity of fluid within the theca. O'Halloran men- 
tions the effusion of coagulated blood on the sheaf of the cord, 
for four inches in length, as it passes the lumbar vertebras, and 
that the intervertebral substance was black and blue, as if from 
the effects of a contusion previous to death. The eye is de- 
scribed to be extremely hard, firm, and yellow externally. 

[Louis found no constant especial alterations in the brain, and 
the spinal marrow presented nothing remarkable. Imray says, 
" The appearances presented on examination of the head were 
chiefly congestion of the sinuses, increased vascularity of the 
brain and of its membranes; the latter were in some cases thick- 
ened,, and occasionally there was serous effusion in the ventricles 
and at the base of the brain."] 

The lesions within the cavity of the chest are not very remark- 
able. Sometimes the pericardium contains an unnatural amount 
of fluid, of a pale yellow colour. The heart does not usually pre- 
sent any other appearance than is common in the muscular tissue 
generally. In the pulmonary tissue the changes observed are 
considered to be only accidental, though Dr. "Browne says that the 
lungs presented, almost always, numerous dark spots externally, 
or were nearly uniformly of a dark colour ; and the infiltration 
of blood into their tissue, forming what is called splenization, 
was very frequent. The bronchial mucous membrane was often 
reddish, and coated with a copious sanguinolent frothy fluid ; in 
other instances it was pale or yellowish, as was also that of the 
trachea. {Edin. Med. and Surg. Journ., vol. xxxv.) 

[The only general morbid appearance which Louis noticed in 
the respiratory organs was a livid colour, more or less marked. 
The exhalation of blood into the pulmonary parenchyma was 
constant and occurred in the following forms. " There were 
either black spots of from two to five lines in diameter, or masses 
of the same colour more or less impermeable to the air, or else 
they were the first and still more rarely the second degree of 
pneumonia. The spots were found in nine subjects, sometimes 
without complication, sometimes with the lesion of which we 
have just spoken. ■ Usually of a brown black, rarely of a crim- 



336 YELLOW FEVER. . 

son hue, they were more or less concentrated, and occupied a 
variable space at the exterior or in the interior of the lung, and 
in some cases they were found only in the lower lobe. The 
density of the tissue, which was the seat of them, was not mani- 
festly increased except in two cases, this increase of density being 
the manifest result of an effusion of blood more or less intimately 
combined with the pulmonary tissue. The blackish masses ex- 
isted in six individuals; their consistence was greater or less, 
they contained no air, they had not the granulated aspect of 
hepatized lung, they presented but slight traces of organiza- 
tion, so that merely some cellular fibres irregularly disposed 
might be distinguished in them. Usually they could be easily 
broken down ; in some cases also they yielded by pressure the 
blood of which they were almost entirely composed, and the 
pulmonary parenchyma remained apparently of its natural con- 
sistence." (pp. 64-6.)] 

In the abdomen, the peritoneum and omentum are often 
slightly injected, and of a dirty yellow colour, without the usual 
natural glistering appearance. The coats of the oesophagus are 
softened and often partially eroded, especially towards its termi- 
nation ; it occasionally presents an appearance, as if some .of the 
black vomit had been poured out from its surface, as well as 
from that of the stomach. [Dr. Louis describes the oesophagus as 
devoid of the epidermis, covering its mucous membranes in six 
cases ; it was partially wanting in nine others, and was perfect 
in five only. The mucous membrane was blackish or of a deep 
brown in six cases ; red, colour of onion parings, or reddish brown 
in three others ; of a proper thickness and consistence in all. The 
black colour was found only where the epidermis was wholly 
or partially destroyed. He does not regard the destruction of the 
epidermis of the oesophagus as peculiar to yellow fever.] 

The stomach is usually distended by inodorous gases, and 
generally contains much of that peculiar dark-coloured fluid, the 
black vomit. Sometimes the cpntained fluid is pale and viscid, 
with flakes floating in it. Blood is occasionally effused upon its 
mucous surface, and sometimes small quantities are enveloped in 
flakes of a dirty ropy fluid. The vessels of this organ are gene- 
rally gorged with blood, especially towards the cardiac orifice. 
The orifices of numerous canals may be seen, from which, by 
pressure, a dark fluid oozes, which is no doubt the black vomit. 
Dark patches of various extent and appearances are found around 
the cardiac orifice, with more or less of punctuated redness in 
the large curvature ; over the rest of its surface it is of a rose 
shade. Occasionally it exhibits an appearance as if a bit of the 
mucous coat had been pinched out, but there is very rarely soft- 
ening, thinning, ulceration or gangrene. [In the examinations of 



ANATOMICAL CHARACTERS. 337 

Louis, the colour of the mucous membrane of the stomach 
varied in different cases and in the same case. In one case it 
was universally red except near the pylorus; in five others 
through a more or less considerable part of its surface. Instead 
of a red colour there was an orange or slight rose tint, or a colour 
of onion parings, in a varying extent, in eight others. In two 
cases there was a ruddy or bister hue ; a greenish or yellowish 
in two others. The colour of the membrane was natural in three 
subjects only. These changes of colour were independent of the 
contents of the stomach ; and M. Louis is of opinion that they 
were not much more frequent than in those who die of the acute 
diseases of Paris. The thickness of this membrane was natural 
in half the cases. In other cases it was thickened. Its consist- 
ence was normal in thirteen cases 3 in ten the membrane was 
softened. This softening, M. Louis thinks, was the result of 
inflammation in the majority of cases; in seven it was associated 
with thickening and redness. He remarks that " it is hardly less 
frequent after other acute diseases, but what makes it more 
important in this fever is the rapidity with which it took place. 
The disease was short, and the gastric mucous membrane was 
not affected in all the cases at the commencement of the fever, 
or at any rate according to all appearance it was not." The 
mammillated appearance was found, and usually to a remarkable 
degree, in fifteen subjects. In all the cases this appearance was 
associated with either thickening or softening, or both these con- 
ditions conjoined, and was evidently the product of inflammation. 
Ulcerations of the gastric mucous membrane were found in two 
cases only, a proportion not exceeding that observed in cases of 
death from other acute diseases. The contents of this organ were 
not the same in all subjects. Their predominant colour was red, 
more or less inclining to black. The duration of the disease had 
little appreciable influence on this colour. The red or black matter 
varied in quantity from four to twenty ounces, and the deeper its 
colour the more abundant it was. The red and black matter did 
not differ in consistence. The latter separated, on standing, into 
two parts: the one superior, more liquid, of a bister colour; the 
other inferior, less abundant, and, as it were, formed of blackish 
particles. It was not mixed with clots of blood ; but M. Louis 
has no doubt of its containing it for the vessels in which it was 
kept, and bodies plunged in it were stained red. What was the 
mechanism of its formation ? There was no vessel ruptured in 
the whole tract of the alimentary canal and no lesion of the 
gastric mucous membrane, so that it must be considered a pro- 
duct of the exhalation of this membrane. 

Dr. Ashbel Smith's description of the condition of the sto- 
mach is as follows : "On pouring off the black vomit, which the 
stomach in all fatal cases contained, and detaching from the 
22 



338 YELLOW FEVER. 

mucous coat the adherent dark-coloured flocculi, this tissue was 
found of a dull pearlish white colour, thickened and softened. 
In some cases the softening was so great that the villous coat 
could be scraped in portions almost into a pulp with the ringers. 
The thickening was not uniform, but presented in portions rugae, 
and an uneven surface like the ' unevenness of the rind of the 
lemon,' (corresponding with the mammillated appearance of 
Louis.) There were a few points, and some scattered stelliform 
particles of a bright red ; but these points and patches would not, 
except in a single case, form, by their aggregation, a surface of 
an inch square. In two cases examined, the whole mucous coat 
presented the white, much thickened and softened condition above 
described: but in four cases, from three-fourths to five-sixths only 
presented this condition commencing at the pylorus, and termi- 
nating within two inches of the cardiac orifice, whilst the remain- 
ing portion, surrounding the cardia, was the seat of a most intense, 
diffuse red injection, preserved its usual firmness, was but little, if 
at all thickened and entirely destitute of flocculi adherent to the 
surface. This injection did not present pointed or stellated patches, 
but the blood appeared to be diffused throughout the mucous 
tissue, and the colour was more or less intense, in proportion to 
the quantity of blood contained in the different parts, and the 
hue was that between venous and arterial blood. The line of 
demarkation between the pale or colourless and injected portions 
of the mucous coat, was, for the most part, as well defined by 
the different thickness of the two portions as by their different 
colour ; the white portion being thickened, whilst the red and 
engorged part still preserved its normal thickness."* 

At the epidemic at Dominica, in 1841, according to Imray, the 
mucous membrane of the stomach presented patches of inflam- 
mation or congestion of greater or less intensity, and was some- 
times thickened. The stomach in every instance examined con- 
tained black vomit. In one case as much as 14 oz. was collected.] 

The small intestines participate somewhat, in the lesions which 
are observable in the stomach. Externally they exhibit, to a 
greater or less extent, vascular arborizations, and are generally 
of a yellow tint; internally, they contain a dark fluid, not unlike 
that which is found in the stomach; this in the lower intestines 
becomes of a thicker consistence ; the villous surface is covered 
with the viscid mucus ; and here and there, but especially in the 
duodenum, patches of a spotty redness may be observed. 
There is rarely, if ever, ulceration or disease of the glands of 
Peyer. The larger intestines usually contain a quantity of pulta- 
ceous black matter. No particular changes, however, are dis- 
coverable in its mucous membrane. [In the Gibraltar epidemic 

* [Ashbel Smith, loc. cit.J 



ANATOMICAL CHARACTERS. 339 

the mucous membrane of the small intestines was slightly soft- 
ened in a few cases, but, in the opinion of Dr. Louis, this soft- 
ening was not, in most instances, of an inflammatory nature. In 
one case Peyer's glands, near the caecum, were slightly tumefied. 
As in the case of the contents of the stomach, those of the small 
intestines were of various appearances. There was in one case 
a yellowish liquid, a more or less viscous and abundant one in 
five others ; a reddish, brownish, blackish, or even entirely black 
matter in fifteen subjects, and blood, recognizable by all its 
external characters, in another. The author is of opinion that 
the stomach is the main source of the black matter, and that it 
passes thence into the intestines ; but in some cases he thinks it 
was the product of exhalation from the mucous membrane of 
the intestines, since it was found there in two instances, when 
there was neither red nor black matter in the stomach. Black 
matter was present also in the large intestines. Dr. Smith found 
the glands of Brunner and Peyer frequently enlarged and " some- 
times greatly developed/'] 

The appearances presented, both externally and internally, by 
the liver, are very various ; it is generally enlarged, heavy and 
gorged with blood; often soft in texture, and easily ruptured. 
O'Halloran, however, describes it in several dissections to have 
been yellow and hard externally and internally, so destitute of 
blood and dried up, as it were, as literally to crumble beneath 
the fingers. Gillkrest mentions much the same appearance; 
he says, that on making deep incisions into its substance, little or 
no blood exuded; and when broken up between the fingers, 
the impression given was what is termed friability of texture. 
Scarcely any trace of bile is to be found throughout its pores. 
[The lesion of this organ found in those dying of yellow fever at 
Gibraltar, Dr. Louis regards as peculiar to the disorder and as 
constituting its anatomical character. He describes it as an alter- 
ation of colour, the organ being sometimes of the colour of fresh 
butter, sometimes of a straw colour, sometimes of the colour of 
co flee and milk, sometimes of a yellowish gum colour, or finally 
an orange or pistachio colour. This discoloration was not the 
same through the whole extent of the liver ; more marked in 
the left than the right lobe : it was also more uniform. In cases 
in which the colour was uniform in the left lobe, there was a 
mixture of gum-yellow, orange, or red points, larger or smaller, 
in the right lobe, or else a rose tint, which did not exist in the left 
lobe. With this discoloration were associated a marked paleness 
and a diminished quantity of blood, so that wherever this appear- 
ance of the liver was decided, the sections of it were dry and of an 
arid appearance in the left lobe. This pale and anemic state of 
the liver was unaccompanied with softening, indeed in several 
cases was associated with increased consistence of the organ. 



340 



YELLOW FEVER. 



Though Dr. L. deems it impossible, in the present state of science, 
to determine the nature of this alteration, he decides, from the 
circumstances just enumerated and the liver being of a natural 
size, that it is not of inflammatory origin. He assigns sufficient 
reasons for the conclusion that this anemic condition is the effect 
neither of hemorrhage from the intestinal canal nor of a deriva- 
tion produced by the inflammation of the mucous membrane of the 
stomach or duodenum. He considers its commencement cotem- 
poraneous with that of the disease, or that it occurs shortly after 
it. It is remarkable that no other organ is in the same anasmious 
condition, and that many of them, as the lungs and stomach, con- 
tain a larger quantity of blood than usual. In the epidemic at 
Dominica, in 1841, this condition of the liver was invariably pre- 
sent. Dr. Catel, of Martinique, found it in all the cases that he 
examined— one hundred and fifty — in the epidemic of 1838-39 
of St. Pierre. In the same epidemic Dr. Rufz met with it in two 
out of three cases. Dr. Ashbel Smith says, " the liver was 
found in all cases of its usual dimensions, of ordinary firmness, 
and without any obvious structural change. In three cases it 
was of a very light drab colour, externally and internally, and 
destitute of blood ; in one of a dark claret colour, and congested 
with blood, and in the others of its usual appearance, and con- 
taining a moderate quantity of blood. In all cases there appeared 
to be a suspension of the biliary secretion ; no bile could be 
squeezed from the substance of the liver." Dr. Nott says, " of 8 
cases dissected during the epidemic of 1843, in Mobile, the livers 
in two only corresponded with the description of M. Louis — they 
were pale, and when torn resembled very closely gingerbread or 
new leather ; and the six others were of a dark blue or dark 
chocolate, presenting different shades of colour, and instead of 
being dry, they were excessively engorged with blood ; the latter 
cases correspond with the description given by Dr. Hulse, of 
the cases dissected in the Marine Hospital at Pensacola in 1841: 
of the 8 dissections in 1844, the livers in 4 corresponded with the 
description of Louis ; 2 were of a dark olive, and 2 were per- 
fectly natural. Taking the whole 16 livers collectively, six were 
some shade of yellow, dry and friable ; 2 olive ; 2 normal, and 
6 darker than natural and much engorged. There can be no 
error in these facts, for Louis' liver was our standard for compari- 
son in .every case." Dr. Nott thinks that Dr. Louis has fallen 
into "another error in supposing this liver to be peculiar to yel- 
low fever — I have repeatedly seen facts to the contrary, and two 
of them have occurred this summer (1844) — one a man by the 
name of Sandy White, who was walking about during the day 
and died at night with violent pains in the bowels ; poison was 
suspected, and the body was opened by several physicians. The 
other was a Frenchman, who was brought from three miles in 



STATISTICS. 341 

the country into the city hospital, dying with protracted bilious 
fever. In both these cases the straw-coloured liver was found, 
without any trace of black matter in the stomach or bowels, or 
other mark of yellow fever." Professor Jackson, in the yellow 
fever epidemic in this city, in 1820, found the liver to vary in 
appearance, never constantly presenting the same aspect. It was 
usually gorged with blood. It is stated, on the authority of the 
late Dr. Physick, that in the previous epidemics in Philadelphia, 
the liver was rarely found much diseased.] The gall-bladder is 
sometimes empty and contracted, at other times distended with a 
grumous mass like tar or molasses; sometimes it contains a minute 
quantity of orange-coloured bile, serum, or pulse : its coats are 
usually very vascular. The biliary ducts are almost invariably 
pervious, with the exception of the cystic, which has occasionally 
been found closed. [Louis found the bile in the gall-bladder 
scanty, thick, and. of a dark green colour. Dr. Nott states that 
the gall-bladder contained bile in all his cases but one ; that it 
varied in quantity from half an ounce to four ounces ; its colour 
was from pale green to olive, and even black ; and of consistence 
from water to tar. In one case the gall-bladder contained about 
four ounces of colourless fluid, resembling gum-water or mucus.] 

The spleen is usually increased in volume and softened. [Louis 
found the spleen natural in one half of the cases ; in some it was 
a little enlarged, in others softened, but slightly so with but one 
exception.] 

The kidneys are, for the most part, of a yellow colour : inter- 
nally they exhibit signs of congestion, and, on minute examina- 
tion, very small abscesses, of which the papillae are the seat, may 
sometimes be discovered. The ureters very generally contain 
pus. The urinary bladder is usually contracted, and its coats 
thickened and hardened ; its internal surface is covered with 
yellow mucus, and, at times, its vessels towards the neck are 
surcharged with dark-coloured blood. [In two of Dr. Nott's 
examinations he found black matter like the black vomit in the 
bladder, and in these the contained urine was bloody.] 

Though these different lesions are most usually met with after 
death from yellow fever, it must be borne in mind, that occasion- 
ally this disease proves so rapidly fatal, that few or none of them 
may be discovered. Under such circumstances there has not 
been time for their development. 



III. STATISTICS. 

The mortality of yellow fever at times is frightful, and most 
uncontrollable. On the first appearance of an epidemic, nineteen 
out of twenty of those attacked die. Nevertheless, the number of 



342 YELLOW FEVER. 

deaths at this early period is not great in proportion to the whole 
population. As the epidemic progresses, the mortality becomes 
less in proportion to the number attacked, but greater in propor- 
tion to the population 5 and diminishes in both respects as the 
epidemic declines. 

[At Gibraltar, in 1828, according to the calculation made by the 
French Commission, from 600 cases, the mortality was in the pro- 
portion of one to six and a half; whilst, according to the tables 
prepared from the published bulletins of the authorities, including 
all the patients in the city and hospitals, the mortality was much 
greater, being 1183 out of 5383, or about one to four and a half. At 
Port Royal, Martinique, between the years 1820 and 1827 it varied, 
in different years, from one in two and a half to one in five. In 
1838 it was one in six. In 1804, in Gibraltar, out of a population 
of nine thousand civilians, but twenty-eight persons escaped an 
attack, and the deaths amounted to more than one in three. Mus- 
grave gives a scarcely less terrible account of it in Antigua in 
1816. In Jamaica, according to Dr. Hume, three out of four died. 
In Philadelphia, in 1820, eighty-three out of one hundred and 
twenty-five perished, or about two out of three. In the same 
year, at Xeres de la Frontera, in Spain, the loss was 70 per cent.* 

At Gibraltar the degree of malignity was very uniform. In 
September 950 persons were ill, of whom 150 died; in October 
3050, of whom 703 died ; in November 1040, with 251 deaths; 
and in December 175, and 47 deaths.] 

Individual liability to the disease is very much influenced by 
age, sex, constitution, and occupation. The susceptibility and 
mortality are greatest in youth and robust manhood ; nearly half 
those attacked are between the ages of fifteen and forty-five. 
This may, in some respects, account for the dreadful mortality 
which has occasionally taken place among the troops and seamen 
sent to districts liable to the disease. On the other hand, children, 
old people, and persons of weakly constitution frequently escape. 
According to Townsend, of 16 cases which occurred at New 
York, 5 were between the ages of 1 and 10 ; 17 betwixt 10 and 
20 ; 40 betwixt 20 and 30 ; 40 betwixt 30 and 40 ; 36 betwixt 40 
and 50; 15 betwixt 50 and 60 ; 6 betwixt 60 and 70 ; 2 betwixt 
80 and 90. Of this number, six only were coloured persons, of 
whom three were blacks and three mulattoes. Of the whole 
number fifty-nine were females; the mortality amongst whom, In 
reference to men, was as one to three. From the above table it 
appears that two-thirds of the deaths occurred between the ages 
of 20 and 50; and that of the remainder, nearly as many were under 
20 as above 50 : there were more than three times as many be- 
tween 10 and 20, as between 1 and 10 ; and nearly twice as many 

* [Dickson's Practice of Physic, vol. i., p. 352.] 



STATISTICS. 343 

between 50 and 60 as between 60 and 90. It is a little remark- 
able, that very nearly the same numbers died between the ages 
of 20 and 30, 30 and 40, and 40 and 50. 

Females are not only less susceptible of the disease, but they 
are rarely attacked with the more severe forms : it is in them 
generally mild, unless during pregnancy, when it is almost inva- 
riably fatal. 

[At Gibraltar the mortality was found to vary according to age 
and sex. The ratio, as stated by the Commission from the docu- 
ments they collected, was : — of children attacked one in seven only 
died ; of women one in five and a half; of men one in four and a 
half] 

With respect to constitution, persons of a plethoric habit are 
more liable to it than those of lax fibre. General observation has 
shown that Europeans, or those of northern latitudes, are, on their 
arrival in places where yellow fever is endemic, more susceptible 
of its influence than natives, which is an additional explanation of 
the excessive mortality among the troops sent out to such situations. 
The immunity from the disease enjoyed by the natives and resi- 
dents of those climates is lost if they leave for a period and again 
return, as they are found to be equally subject to attack as the 
new settlers. The heat of the body in new comers to the West 
Indies, has been observed by Dr. M'Kittricx to be between 
three and four degrees higher than in the natives. This fact may, 
in some measure, account for the predisposition of new comers to 
yellow fever. 

With regard to occupation, bakers and cooks are particularly 
prone to severe attacks, while butchers, tanners, soap and candle- 
makers enjoy, in some degree, immunity : the same has been 
observed among those engaged in potash and soda works in New 
York. 

Yellow fever may be said to be proper to places situate between 
40° north and 20° south. It appears to require a climate in which 
the mean summer range is not less than 75°; and, according to 
some authors SO . Dr. Smith says, that temperature has evi- 
dently a more marked share in checking the disease than winds 
or rains, for that frequently, during an epidemic, storms have 
occurred without producing any perceptible effect ; but the mo- 
ment the temperature becomes reduced, the fever subsides, and 
in one night, sometimes, the generation of the febrific poison may 
be said to cease. 

The history of many other places is also a proof of this. In the 
West India islands it is rarely found to occur in the cooler climates, 
which the elevation of 1600* feet affords. At Stony Hill in Jamai- 
ca, which is 1300 feet above the level of the sea, and has a mean 
annual climate of 70°, this fever is only of occasional occurrence, 



344 YELLOW FEVER. 

and rarely epidemic. At the same time it does not follow that it 
occurs in all places which have a temperature ranging about 80°; 
or that in places where it is endemic, a year of peculiar heat 
necessarily gives it this epidemic character. On the contrary, the 
opposite is often the case, of which many striking instances might 
be quoted. It appears, also, notwithstanding the statement of 
Dr. Smith just referred to, that the epidemic increases in a quiet 
state of the atmosphere ; while, during the prevalence of gales, 
tornadoes, and other climatorial convulsions, this fever rarely 
prevails. 

To enumerate the situations in which yellow fever occurs, 
would include almost the whole catalogue of places with a mean 
temperature of 75°, whose shores are washed by the seas between 
the latitudes we have mentioned. It is the devastating pestilence 
of the places which come within this scope in America, in the 
West Indies, in Europe, and in Africa. 



IV. PROGNOSIS. 

In forming an opinion of the probable result of yellow fever, 
the character of the prevailing epidemic, the age, constitution, and 
residence of the patient should be taken into consideration. The 
symptoms which augur an unfavourable termination are, general 
depression supervening immediately on the attack, or occurring 
suddenly in the progress of the disease ; an early yellowness, and 
especially an olive or dark tinge of the skin ; coldness of the sur- 
face ; weak irregular pulse ; tendency to faint ; deep sighing ; con- 
stant vomiting ; small whitish stools ; suppressed urine ; tremors ; 
subsultus tendinum ; coma and singultus; red, injected, protube- 
rant eyes ; dilated pupils ; offensive breath ; petechia? and vibices; 
and dark involuntary evacuations by urine and stool. The black 
vomit is generally a fatal sign, though many have survived this 
symptom. 

[Dr. Dickson says, "The individual prognosis is much varied by 
circumstances. The attack is apt to be violent, and its progress 
hasty, in the sanguineous and plethoric. For the intemperate 
there is almost no hope. National habits and modes of life have 
a decided influence. The Irish, Germans and Scotch afford us 
the worst cases ; Spanish, Italians and Frenchmen are very apt 
to recover. Midway stands the Englishman, the northerner, and 
the mountaineer, or inhabitant of our interior country. Generally 
speaking, the more recently a stranger has come here, the more 
severe his attack. Among the young children assailed the ravages 
of this pestilence are very great. Rush notices the large mortality 
among them in Philadelphia, in 1793; and the mothers of Charles- 



PROGNOSIS. 345 

ton long remembered with tears the unhappy summer of 1817."* 
At Dominica, Dr. Imray observes that, with few exceptions, the 
fever was confined to the European population, the symptoms 
being modified and in general rendered milder by a residence of 
some years in the colony. Of twenty-eight Creoles that Dr. Rufz 
treated at St. Pierre, two only died, whilst at the Marine Hospital 
the mortality was one in five. A moist and relaxed skin was 
regarded by Rush as an unfavourable sign, an opinion in which 
Dr. Dickson coincides. A spontaneous suppression of urine is 
almost uniformly a fatal sign. Dr. Imray, speaking of the super- 
vention of fatal symptoms, says, " a quivering of the muscles of 
the face is observed ; a few clots of blood escape from the gums; 
and mucus, mixed with dark flakes, is coughed up ; these pheno- 
mena are the almost certain precursors of death."! He adds that, 
in the epidemic of 1841, there was no instance of recovery after 
black vomit appeared, but that more cases with bleeding of the 
gums recovered than in 1838. Dr. Dickson has not found the 
occurrence of black vomit invariably mortal, as he has seen ten 
instances in his own practice of recovery after it had appeared. 
Dr. Louis remarks that the same symptoms have not the. same 
value for prognosis at all periods of life ; thus the black vomit, 
which in men was the most certain harbinger of death, took place 
in a great many children who recovered.] 

The favourable symptoms are, the pulse maintaining a degree 
of strength after the third day ; a soft skin of moderate tempera- 
ture ; the absence of vomiting, and of severe pain of the eyeballs; 
free perspirations ; abundant secretion of high-coloured urine ; 
bilious diarrhoea, especially if followed by quiet and refreshing 
sleep. The appearance of the cutaneous efflorescence, called 
prickly heat, is also favourable. 

[The supervention of some degree of febrile excitement after 
the subsidence of the original paroxysm, is favourable, and is 
spoken of by Dr. Robert Jackson, as "a new stream of life," for 
it is at this stage that sudden and fatal collapse is so apt to occur.] 

Though, speaking in general terms, these signs form sufficiently 
accurate grounds of prognosis, yet they are not always implicitly 
to be depended on : sometimes, when the worst consequences 
may be anticipated, a change takes place, which is followed by 
perfect recovery ; at other times, when everything appears favour- 
able, some peculiar state suddenly ensues, which rapidly places 
the patient in danger. 

* [Dickson's Practice of Physic, vol. i., p. 353.] 
f [Imray, loc. cit., p. 329.] 



346 



YELLOW FEVER. 



V. DIAGNOSIS. 



It would be almost impossible to describe, in a few words, any- 
very particular or well-marked symptoms, by which yellow fever 
can be sufficiently distinguished from some of the diseases with 
which it is nearly allied, and may be confounded. In order fully 
to appreciate the differences between them, their whole pheno- 
mena should be studied. The statement of Mr. Amiel is very 
just, that this fever has no specific character, no appropriate es- 
sential, or pathognomonic symptom, no definite duration; but 
that its prominent features are, pain in the head and loins ; strong 
and quick pulse ; turgidity of the vessels of the conjunctiva ; moral 
and physical prostration; sensibility and irritability of the epigas- 
tric region; anxiety; dry red tongue ; yellow tinge of the skin; 
great variation in the urinary secretion ; passive hemorrhage 
from the nose, tongue, gums, and bowels; dark or even black 
vomitings or dejections ; delirium, coma, &c. The whole or part 
of these symptoms appearing together, form the most sure diag- 
nostic of this fever. 

[In severe and fatal cases the diagnosis of yellow fever is 
easily made. In mild cases, especially where there is no de- 
clared epidemic, the diagnosis is often extremely difficult. Dr. 
Louis says, in mild cases, all the more or less characteristic 
symptoms were often wanting. Frequently there were no vomit- 
ings of any kind, never black vomit, nor black dejections, nor 
yellowness, nor anxiety. The disease appeared to consist of some 
slight febrile symptoms, to which were joined a more or less 
intense headache, pain in the limbs, back, and loins ; sometimes, 
usually even, redness of the eyes; a weakness so moderate, that 
many patients did not keep their beds. In cases of this sort, 
occurring at the commencement of an epidemic, the character of 
which has not been recognized, and where the patients observed 
are isolated, it is not only impossible to recognize the disease, but 
we should scarcely even suspect it. It might be taken for an 
ephemeral fever, the character of which cannot always be deter- 
mined, or in cases where the febrile symptoms are accompanied 
by epigastric pain and nausea, the disease might be considered a 
slight gastritis ; and although, according to observation, the return 
of strength does not take place in yellow fever patients after a 
space of time proportioned to the symptoms and duration of the 
fever, still so many causes may retard convalescence from the 
most common diseases, that yellow fever could not be suspected 
from this consideration alone. But if many similar cases were 
observed in a short space of time, in the months of August and 
September, and in the latitude where the yellow fever prevails ; 



DIAGNOSIS. 347 

if the eyes were injected from the commencement, the counte- 
nance red, the headache intense, the epigastrium sensible on pres- 
sure, we should strongly suspect this disease, although the exist- 
ence of an epidemic has not been declared. There would be no 
doubt as to this point, even if the symptoms existed in the slightest 
degree only, where the disease attacked all the members, or the 
greater part of the members of one family, and in a short space 
of time ; since, of diseases of this kind there is no other than yel- 
low fever, which would attack a great number of persons of the 
same family in so short a space of time.] 

We have previously referred to the opinion which has been 
entertained, that distinct remissions are a part of the phenomena 
attendant on this disease. In consequence of this, Dr. Pinckard 
and many others regard yellow fever to be not a distinct or spe- 
cific disease, but merely an aggravated degree of the common 
remittent or bilious fever of hot climates, rendered irregular in 
form, and augmented in malignity, from its occurring in persons 
unaccustomed to the climate. In this view they think they are 
especially supported by its exhibiting so great instability and 
variation of character. We have, however, previously shown, 
that there is every reason to conclude, that yellow fever is not 
attended by a perfect and distinct remission ; and that, although 
many conceive it to be more nearly allied to the remittent than to 
any other type of fever, it is in the absence of remittence the chief 
difference consists. Dr. Stevens states as a diagnostic distinction, 
that in remittent fever the blood, when drawn at the commence- 
ment of the attack, is both buffed and cupped, which is not the 
case in yellow fever ; that in this latter, though there may be a 
very low state of the temperature of the body, there is never any 
rigor ; that the patients do not shake nor tremble like those who 
are under the influence of the marsh poison ; and that there is an 
expression of the countenance which is peculiar to it ; which, 
though not so marked as the expression in tetanus, is yet so dis- 
tinct, that those who have once seen it can easily recognize it. 

[The distinction between yellow fever and severe bilious remit- 
ting fever is thus ably traced by Dr. Stewardson. In yellow 
fever, " the fever is generally, if not always, of the continued type ; 
and hence this feature alone would be sufficient to settle the ques- 
tion, where we have an opportunity of carefully watching a case 
from the commencement. But unless other differences could be 
pointed out, it might be fairly questioned whether the two dis- 
eases were essentially distinct. In remittent, then, let us recol- 
lect, that the matter vomited is usually bilious throughout, whilst 
in yellow fever it is first clear, then yellowish, and finally blackish, 
or completely black. It is said also that in the latter the stomach 
is emptied without effort, and the desire to vomit ceases for the 
time, whilst in remittent the act of vomiting is painful and diffi- 



348 YELLOW FEVER. 

cult, and the nausea persists. In remittent, there is a tendency 
to fullness of the hypochondriac and epigastric regions, whilst in 
yellow fever, according to Louis, the abdomen uniformly pre- 
serves its natural form. I cannot help thinking that this differ- 
ence in the conformation of the upper part of the abdomen, will 
be found to be an important distinctive feature ; but to determine 
the question requires further observation, and I therefore throw 
it out as probable merely. The probability is to my mind much 
increased by considering that in remittent the spleen and liver 
are, generally at least, enlarged, and often to a great degree, 
especially the former, whilst in yellow fever they preserve their 
natural size, or nearly so, and hence we should naturally expect 
a corresponding difference in the conformation, at least of the 
hypochondria. In remittent, also, the hypochondria?, especially 
the left, are sometimes painful, a condition, so far as we are 
aware, not noticed in yellow fever. The character of the yellow- 
ness is said to be different in the two diseases; and Dr. Stevens 
affirms that in yellow fever the patients do not shake nor tremble 
like those who are under the influence of marsh poison, and that 
the expression of countenance is so peculiar, that those who have 
once seen it, easily recognize it. R. Jackson, also, in his account 
of the fevers of Jamaica, says that the horror and shivering which 
so usually precede fevers, were seldom great in degree in the dis- 
ease before us. Cramps, too, are said to be much more frequent 
in this than in remitting fever. Such appear to be the principal 
points of difference, so far as regards the symptoms ; and if we 
consider them in connection with other differences presently to be 
mentioned in reference to the origin, prevalence, &c, of the two 
diseases, the very opposite condition of the liver and spleen, as 
discovered by post-mortem examinations, and the presence of a 
brown or black matter in the stomach and intestines in the one 
case, which is not met with in the other, it seems to me that it is 
scarcely possible to avoid the conclusion that the two diseases are 
essentially distinct. The enlargement and softening of the spleen 
in bilious remittent, and other types of fever of malarious origin, 
is a prominent fact attested by most writers ; and this fact alone 
is almost sufficient to convince us that yellow fever, in which the 
spleen rarely presents any considerable traces of disease, must be 
essentially distinct in its nature. The very opposite conditions of 
the liver are also especially w r orthy of notice; that in yellow fever 
being anemic, with deficiency of bile in the gall-bladder, — that of 
remittent being usually enlarged, and with the gall-bladder fully 
distended."* Dr. Wurdemann observes, " If I were asked what 
was the most prominent pathognomonic symptom in yellow fever, 
one that most distinguished it from those cases of remittent bilious 

* [Stewardson's edition of Elliotson's Practice of Medicine, p. 356.] 



NATURE. 349 

fever complicated with gastritis, so prevalent during epidemics of 
the former, I would answer, the total cessation, or the much 
diminished and vitiated secretion of bile. For although it is some- 
times ushered in by bilious vomiting, the bile thus ejected has 
been mechanically forced from the gall-bladder, where it had been 
collected previous to the attack. It is very certain that the resto- 
ration of the functions of the liver is the most favourable symptom 
in the course of the disease. The physiognomy of yellow fever 
differs also from that of the most aggravated cases of remittent 
bilious fever. In the former, there is a peculiar glassy appearance 
of the eyes, even when they are but slightly red ; an anxious ex- 
pression of the countenance, that the real or assumed calmness of 
the patient cannot entirely control ; and a constant, but more or 
less strongly marked torpor of the cutaneous circulation, evinced 
by the slow return of blood pressed by the finger from the in- 
jected capillaries, as if these vessels were in a state of passive 
hyperemia."*] 

It may be distinguished from plague by its existence in a tem- 
perature which puts a stop to the progress of this disease by the 
non-appearance of buboes or carbuncular eruptions, and by its 
being always ushered in by a violent febrile paroxysm, which is 
not usually the case in plague. 

From typhus it may be known by its not occurring in cold 
weather ; by its attacking the young and robust ; by the yellow- 
ness of the skin; pain of eyeballs, &c; and by its occasional 
termination in intermittent and remittent diseases. 



VI. NATURE. 

Very different opinions are entertained respecting the nature 
of yellow fever. Some, with Tomasini, Pringle, Lind, Mosely, 
Pinel, Rubini, and others, maintain that it is a general pyrexia, 
complicated with inflammation of the liver and internal surface 
of the stomach and intestines. Bailly and Bancroft associate 
it with typhus fever, and ascribe the fatal cases to lesions of the 
brain and stomach. Others regard it as a variety of remittent 
fever. [Nearly all the late writers on yellow fever agree in re- 
garding it as a continued fever, (see p. 32.) " It may be fairly 
doubted," Dr. Stewardson observes, " whether it is ever cha- 
racterized by regular and distinct remissions. Towards the third 
or fourth day, especially in the inflammatory form, there appears 
to be sometimes a rapid abatement of the more violent symptoms; 
the pulse falls, and the skin becomes cool. This abatement, how- 
ever, is but the precursor of a favourable, but more commonly of 
a fatal termination, and not to be confounded with a true remis- 

* [Am. Journ. Med. Sciences, Jan. 1845, p. 51.] 



350 YELLOW FEVER. 

sion. It is also said, that shortly after the attack has commenced, 
in the course of the first twenty-four hours, the patient will ex- 
press himself as feeling better, although the symptoms indicative 
of intense disorder, still persist. 'A trifling abatement of the 
symptoms,' says Dr. R. Jackson, < was sometimes taken notice 
of, in ten or twelve hours after the commencement, but in no 
instance, so far as I have observed, was there ever so much 
alleviation, as with any justice could be called a remission.' It 
is not unlikely that these changes, especially where the mind of 
the observer was already prepossessed with the idea that yellow 
and remitting fever were essentially the same affection, may have 
led to the supposition that the former presented a truly remitting 
character. That it ever does so, appears at least to be very doubt- 
ful."* Dr. Imray, speaking of the two epidemics in the island 
of Dominica, remarks, " Yet could the term remitting in no way 
be applied to the fever, for even in the mildest cases the peculiar 
and distinctive symptoms of the epidemic were always present. 
* * * * It cannot be called periodic, for in every instance almost 
it marches on with a steady pace, either to a fatal issue or 
recovery. There are, in general, absence of rigors, a stage of ex- 
citement of greater or less intensity, the singular subsidence of the 
increased vascular action, the absence of pain, cool skin, cerebral 
and nervous symptoms, black vomit, and death."!] 

With few exceptions, however, it is now viewed as a specific 
disease; and, as such, its proximate cause, or essential nature, 
has given rise to much discussion — some referring it to the lesions 
of the solids, others to disorganization of the fluids. 

With some slight modifications, Broussais, Dubreuil, and 
Boisseau, regard the phenomena of the disease as the sequel of 
a primary inflammation, of the gastro-intestinal inflammation. 
Dr. Wilson, (Memoirs of West Indian Fever,) who says that 
there is a want of consent between the power of the disease and 
its external manifestations, maintains that it is owing to the pre- 
sence of a peculiar morbid affection of the alimentary canal ; 
others attribute it to disorder primarily taking place in portions of 
the nervous system — the brain and spinal column, according to 
M. Francois and Boyle. Dr. Gillkrest says, that the uniform 
integrity of the cerebral functions in the first stages of this malady, 
as observed at Gibraltar in 1828, and as noticed on other occa- 
sions, the extremely frequent integrity of these functions to almost 
the last moments of existence in its congestive or more intense 
and fearful form, together with the remarkable manner in which 
the secretions are often suspended, induce him to think that the 
ganglionic system is involved very prominently in the series of 
i 

* [Stewardson's edition of Elliotson's Practice, p. 357.] 
f [Ed. Med. and Surg. Journ., October, 1845, p. 321] 



NATURE. 351 

morbid actions. Dr. Craigie attributes the phenomena to a 
general affection of the capillary vessels, which is an application 
to this disease of the views he entertains of fevers generally. 
The chief advocates of the theory, that yellow fever originates in 
disorder of the fluids, are Gtjyon, De Fermon, and Dr. Stevens. 
The latter states that the disease is caused by an animal poison 
which remains dormant in the system about four days, during 
which it effects certain changes in the blood, which unfit that fluid 
for nourishing the system. Not only does it become darker in 
colour but altered in composition, as is evident from its having, 
when first drawn, a peculiar smell, and its almost invariably 
coagulating without a crust ; from the appearance of black spots 
on the surface of the crassamentum, by the coagulum being soft 
and easily separated, and by a large quantity of black colouring 
matter falling, during its formation, to the bottom. Moreover, 
when the serum separates, it has generally a yellow, in some 
cases a deep orange colour. He says that these derangements 
are often so apparent, that in some instances, where the indi- 
viduals have been accidentally bled, he has been able to foretell 
an attack of fever, merely from the appearance of the blood 
which had been drawn previous to the commencement of the 
cold stage. The intermixture of the poison with the blood (Dr. 
Stevens supposes) causes a deficiency in its saline constituents; 
the results of which are, that in the early stage of the disease the 
structure of the red globules becomes deranged, so that they do 
not separate freely and entirely from the serum, but are partially 
dissolved in it, while in the advanced state they become entirely 
black, and the whole mass of the blood thin and poor. This 
state is evinced during life by the oozing of black fluid blood 
from the tongue, eyes, skin, or other surfaces, and by the condi- 
tion of the blood in the dead body. With regard to the change 
of colour in the blood, Dr. Stevens states, that in the commence- 
ment of the fever, it is dark from the effect of the poison, and 
that in the last stage it appears to be black merely from the loss 
of its saline matter :* for when we add any of the natural saline 
ingredients to the black fluid which is taken from the body late 
in the disease, it becomes florid, and more healthy in appearance 
than when the saline matter is added to the poisoned blood drawn 

* As these statements involve the accuracy of many of the received views 
and opinions on the arterialization of the blood, Dr. Turner made a series of 
experiments, from which he says, that he is at a loss to draw any other infer- 
ence than the following: — That the florid colour of the blood is not due to oxygen, 
but, as Dr. Stevens assumes, to the saline particles of the seram. The change 
from venous to arterial blood appears, contrary to the received doctrine, to con- 
sist of two parts, essentially distinct; one is a chemical change essential to life, 
accompanied by the absorption of oxygen and evolution of carbonic acid ; and 
the other depends on the saline matter of the blood, which gives a florid tint to 
the colouring matter, after it has been modified by the action of oxygen. 



352 YELLOW FEVER. . 

from the system before the attack. He, therefore, thinks it pro- 
bable that the greater part of the poison is either changed ill its 
properties during the disease, or thrown out of the system in its 
original form by the secreting organs. This morbid condition of 
the blood he concludes to be the first link in the chain of those 
phenomena which constitute fever ; for, as this pernicious blood 
circulates, it acts on every fibre and on every tissue of the living 
system, disturbs every function of the body, and deranges every 
faculty of the mind, while all the excretions have a morbid ap- 
pearance, and the secreted fluids are changed both in quality and 
quantity. 

[Two recent writers on the pathology of yellow fever express 
the opinion, that the disease is due to the introduction into the 
blood of a poison from without, which propagates itself by zymo- 
tic action, causing profound alteration of that fluid. " Who/' 
says Dr. Nott, " can hesitate to regard yellow fever as a well- 
marked case of poisoning ? Sometimes a patient coming into the 
infected district, in perfect health, is stricken down by this poison 
with the rapidity of lightning ; the powers of life are annihilated 
at once, and in 24 hours he dies without recovery from the first 
blow. I have seen several the last winter whose first symptoms 
were coma, convulsions, or both. How different from local in- 
flammations."* "Post-mortem examinations," remarks Dr. Im- 
ray, " have done but little in unfolding the real nature of yellow 
fever. Indeed, the more the disease is studied, the deeper becomes 
the impression that the poison acts chiefly on the vital fluids. It 
would seem in many cases as if the blood were that part of the 
system from which the vital principle began first to be withdrawn. 
It need not be repeated that the morbid changes observed in the 
stomach and brain, at least such as are appreciable to our senses, 
can scarcely be considered as accounting satisfactorily for the 
symptoms and rapid course of the fever. The gastric and cere- 
bral symptoms are probably only consequences or concomitants, 
for sometimes there is little or no irritability of stomach, though 
the black vomit is almost always foundin that organ. Many cases, 
likewise, terminate fatally without the presence of such disorder 
of the cerebral functions as can in any way account for death."t] 



VII. CAUSES. 

The opinions which are entertained respecting the causes of 
yellow fever may be arranged under three heads: — 1. That it is 
a disease essentially of endemic origin; 2. That, being of endemic 
origin originally, it becomes contagious; 3. That it is solely and 

* [Am. Journ. Med. Sciences, April, 1845-.] 
\ [Ed. Med. and Surg. Journ., Oct., 1845.] 



causes. 353 

essentially induced by contagion. Those who entertain the first 
view are by no means unanimous as to the nature of the endemic 
cause to which they attribute the origin of this fever. Almost 
every possible physical condition has in its turn been thought to 
be the true one. Marsh miasm has been very generally regarded 
as the origin of yellow fever. Dr. Bancroft, who is one of the 
most able writers on the subject, says, that those whose minds 
are unbiased will clearly recognize in this disease all the peculiar 
features and characteristic marks by which marsh fevers are dis- 
tinguished in all parts of the world ; and they will naturally con- 
clude that, though it be the most aggravated and violent of the 
fevers arising from miasmata, this aggravation and violence are 
produced only by a greater concentration or virulence in the 
latter, joined to a greater intensity of atmospherical heat, acting 
on persons but little accustomed to bear it, whilst they retain the 
excitability of cold or temperate climates, together with an 
habitual disposition to generate that portion of animal heat which 
such climates require. In this opinion he coincides with Dr. 
Rush, who says, that we might as well distinguish the rain 
which falls in gentle showers in Great Britain, from that which 
is poured in torrents from the clouds in the West Indies, by dif- 
ferent names and qualities, as impose specific names and charac- 
ters upon the different states of bilious or marsh fevers. Without 
entering again into the question of the identity of these diseases, 
there can be no doubt that yellow fever, in common with fevers 
whose origin is undoubtedly due to marsh miasmata, often as- 
sumes a peculiar virulence of character in situations which are 
favourable to these latter ; and that it is in such situations in hot 
climates where malaria are prevalent, as at the estuaries of rivers 
and the shelving shores of the sea, that yellow fever is most 
usually met with ; and that it occurs both sporadically and epi- 
demically in the same seasons, in which experience has taught 
us malaria give rise to intermittent fevers. Opposed, however, 
to the view, that yellow fever is owing to marsh exhalations, are 
the facts that it very frequently prevails where no cause of this 
kind can be traced to be in operation ; and that marshes often 
abound in hot latitudes without the disease occurring in the 
neighbourhood. Numerous instances have been brought forward 
to show that it prevails where there is no marsh exhalation. Its 
occurrence on shipboard without there being the least possibility 
of tracing the presence of marsh vapours to the ships themselves, 
or to the places near to which the vessels are moored, has been 
particularly dwelt on. Bancroft endeavoured to show, that in 
these cases it was owing to decomposition taking place in the 
ballast, or to the putrid state of the bilge-water. Subsequently 
to these views having been expressed, the possibility of the first 
has been obviated by the adoption of iron ballast, and of the. 
23 



354 YELLOW FEVER. 

second by the frequent changing of the water, yet the fever has 
equally prevailed. At Barbadoes the physical characters of the 
island are such as to preclude entirely the idea of the existence 
of marsh exhalation ; besides which, from its having been for a 
long period in a state of the highest and most complete culti- 
vation, it is trenched, drained, and cleansed, and has undergone 
all those improvements which render a territory, as far as possi- 
ble, free from marsh exhalation. Corresponding with these pecu- 
liarities of its physical structure is the fact, that none of the 
modifications of ague are endemic in Barbadoes. Yet yellow 
fever has been at ail times, and still continues to afflict the popu- 
lation of this island in the severest forms of the disease. 

With regard to the second point, that it does not occur in situa- 
tions where marshes abound, Dr. Wilson [Edin. Med. and Surg. 
Joarn., vol. xxxv.) quotes the very strong case of its not being a 
disease of Rio Janeiro, and contrasts it with its prevalence at Vera 
Cruz — both under nearly equal parallels of latitude; both built on 
a low sea-shore ground, skirted by high mountains, though at 
unequal distances ; the religion of the inhabitants the same, and 
their habits and modes of life very similar. Yet, while Vera Cruz, 
without a rood of marshy soil, is a hot-bed of West Indian fever 
in its most violent forms, in Rio Janeiro, though situated near an 
extensive swamp, and liable to ague, yellow fever is never known. 
In Honduras, also, which is situated close to the sea, and occupies 
part of a large bog, and is during the rainy season so perfect a lake 
that teal and snipe may be shot from the windows, while in dry 
weather it becomes so parched that the inhabitants have difficulty 
in procuring water, though the inhabitants suffer much from in- 
termittent and remittent fevers, the yellow fever is comparatively 
unknown. The same immunity is enjoyed by Demerara, which 
settlement is a narrow tract, low, level, extending along the sea- 
coast, and intersected with canals and ditches, alternately inun- 
dated and covered with stagnating oozy water abounding with 
vegetable matter. Here the soil is a swamp, and the ditches are 
marshes ; nevertheless, the yellow fever is an exceedingly rare 
disease. 

[The common origin of yellow fever and intermittent and re- 
mittent fevers, has been largely examined and ably discussed by 
Dr. Imray in the communication so often referred to. It has been 
asserted by Chervin and others that yellow fever belongs to the 
family of intermittent and remittent fevers, of which it is merely 
the highest degree, and that they are all produced by the same 
cause in different degrees of concentration. To the making out 
of this position, Dr. Imray observes, "there are many insurmount- 
able difficulties. If it be assumed that the epidemic febrile dis- 
order usually recognized as yellow fever, is identical in cause 
with the endemic periodic fevers of these islands, it is natural to 



causes. 355 

conclude that where those diseases most prevail, yellow fever 
ought most to show itself and occur in its most malignant and 
virulent forms. How stand the facts? Compare the islands of 
Dominica and St. Lucia with Barbadoes. The two former com- 
posed of masses of lofty mountains, intersected by deep ravines 
and valleys, and covered in every direction with forest and brush- 
wood, are only under partial cultivation, and abound in miasmata, 
There are situations in both these islands so inimical to the Eu- 
ropean constitution that a residence even for a short time, is almost 
with certainty followed by an attack of intermittent or remittent 
fever. Periodic fevers are of constant occurrence in these islands 
at all seasons, though prevailing more at one season than another. 
Barbadoes, on the other hand, presents comparatively a level sur- 
face, almost entirely under beautiful cultivation. Here are no 
lofty mountains, dense forests, or extensive morasses, and the 
consequence is, as might be expected, that periodic fevers are of 
rare occurrence. Indeed the island is so free from these disorders, 
that persons labouring under intractable intermittents repair thither 
for recovery. But is it equally free from yellow fever? The 
troops have repeatedly and severely suffered from epidemic out- 
breaks of this malady, and the mortality among the civilian inha- 
bitants has at times been very great. And this appears to have 
been the case as far back as 1752, from the work of Hillary on 
the Diseases of Barbadoes; but at that time, it enjoyed no ex- 
emption from yellow fever. ***** Many examples might 
be adduced to show that yellow fever may prevail with great 
malignity, where the intermitting types are scarcely known. The 
troops suffered much for some years from yellow fever at St. 
Christopher's. Burntstone Hill, on which the garrison is placed, 
rises 700 feet above the level of the sea, and is not surrounded 
by any morasses or thick wooded land. There are no pools, 
lakes, or marshes, and the rain pours at once into the sea, 
through deep ravines and clefts. Yet to this dry, rocky hill, 
where intermitting fevers are but rarely met with, did the yellow 
fever cling so pertinaciously, and produce a mortality so great, as 
to occasion the withdrawal of the troops entirely from the island." 

These observations are fully sustained by those of Catel and 
Rufz, of Martinique.] 

Its origin has by others been attributed to intense solar heat, 
acting either per se, or on wet and marshy coasts. Sir Gilbert 
Blane, as previously mentioned, states that yellow fever never 
occurs either in tropical or temperate latitudes, unless the tempera- 
ture has for some time been steadily at or above 80°. It is a mat- 
ter of general observation, that an elevated temperature almost 
invariably accompanies the development of this disease; and that 
near those low situations in which it occurs, places which are on 
a higher level, and the temperature of which is consequently 



356 YELLOW FEVER. 

colder, are not subject to it. Drs. Ferguson and Lind appear 
both, with, certain modifications, to entertain this view of its ori- 
gin. The former states this disease to be owing to a desiccation 
by heat, provided its operation be not disturbed by wind, &c; the 
latter, when defining what unhealthy climates are, says, that in 
such places, during excessive heats and great calms, it is not 
altogether uncommon, especially for such Europeans as are of a 
gross habit of body, to be seized at once with the most alarming 
and fatal symptoms of what is called the yellow fever, without 
having any previous complaint, sickness, or other premonitory 
symptoms of the disease. Opposed to this theory, on the other 
hand, the names of many places may be adduced, in which, 
though having a temperature, according to his view, adequate to 
produce the disease, it does not occur. This, to say the least of 
it, invalidates the opinion that it is solely owing to an elevated 
temperature ; and accordingly we find Dr. Wilson dismissing it 
very summarily, stating that the circumstance of yellow fever 
never having been seen in situations, as Kingstown in Canada, 
Moscow, and various places in Russia, in which the atmospheric 
temperature is equally high during summer as in places noted 
for the prevalence of that disease, affords a satisfactory proof that 
the cause assumed is insufficient to produce the effect. Dr. 
Craigie, who quotes many instances of the same nature, says, 
they are quite sufficient to prove, that the highest degrees of at- 
mospherical or terrestrial temperature are not necessarily enjoined 
with the production of yellow fever; and that, though this disease 
requires a temperature of 74° or 75° for its production, its continu- 
ance is quite independent of this temperature ; and that it irre- 
sistibly, results, that high temperature, or intense and continued 
atmospherical heat, is not the most essential generating cause of 
yellow fever, but that the concurrence of some other circumstances 
is required. It appears, in short, that elevated temperature is 
merely one of many co-existing circumstances which concur at 
the period of yellow fever epidemics. 

[" We know," says Dr. Imray, " that yellow fever is met with 
only in certain parts of the world, and certain localities ; that a 
certain degree of heat, though not the cause, is absolutely neces- 
sary to give activity to the poison. But why in the same place 
and under circumstances apparently similar, it should at one time 
rage with frightful mortality, and at another the inhabitants be 
remarkably healthy, why it should be absent from a country for 
many years, and then break out without the possibility of assign- 
ing a satisfactory cause, are among the many difficulties connected 
with yellow fever that remain to be cleared up. There must be 
some new cause in operation, when these terrible epidemics burst 
out when least expected, or some unusual change in the common 
morbid agencies. It could not be said that the causes of the epidemic 



causes. 357 

still continued to exist in this island (Dominica), and only ceased 
to act because there was no material on which the poison could 
exert its baneful influence ; for the European troops were more 
than once changed, yet not a single instance of yellow fever 
occurred either in the garrison, among the civilian inhabitants, or 
the shipping from 1838 to June, 1840. Moreover, were this the 
case, Europeans would invariably be attacked as they arrived in 
the West Indies. Now, we find that in some colonies, year after 
year passes on, and no case of the disease is met with, while the 
influx of Europeans is still going on. But so soon as the causes 
become developed, then do the natives of cold climates suffer ; and 
if others arrive while the epidemic influence is in operation, the 
risk of attack is very great. At the same time it is perfectly true, 
that yellow fever occasionally disappears in consequence of the 
absence of predisposed individuals, while the causes linger in the 
country, and only manifest themselves on the arrival of Europeans, 
or of others who have become highly susceptible." 

Hillary says, " It does not appear from the most accurate 
observations of the variations of the weather, or any difference 
of the seasons which I have been able to make for several years 
past, that the fever is in any way caused or much influenced by 
them ; for I have seen it at all seasons of the year, in the coolest 
as well as the hottest time of the year, except that I have always 
observed that the symptoms of this (as well as most other fevers), 
are generally more acute, and the fever usually higher in a very 
hot season, especially if it was preceded by warm moist weather, 
than it usually is when more cool."* Dr. Rufz observes, " Now, 
whether the thermometer was high or low, whether it rained or 
was fine weather, hot or cool, yellow fever always prevailed with 
the same intensity, without the character of the season appearing 
in any way to influence its progress." Dr. Craigie remarks, " It 
appears that yellow fever becomes epidemic neither in consequence 
of intense temperature alone, nor humidity alone, nor filth, nor 
the presence of foul docks and wharves, nor desiccated marshes, 
nor decomposed cabbages or coffee, or mangroves, not even 
charred shipholds; but a certain condition of the atmosphere, 
which occurs at very uncertain intervals, and of the recurrence 
of which the circumstances now enumerated are indications.' 7 !] 

Others again, and of these the chief is Dr. Miller of New 
York, state that yellow fever is generated by the impure air or 
vapour which issues from the new made earth or ground raised 
on the muddy and filthy bottoms of rivers, and which deteriorates 
the air above it. Consequently this fever is found to rage chiefly 
where large quantities of new ground have been made by bank- 
ing out the rivers for the purpose of constructing wharves ; and 

* [Diseases of Barbadoes, &c] 

f [Craigie's Elements and Practice of Physic, v. i., p. 236.] 



358 YELLOW FEVER. 

that its great prevalence in New York and Philadelphia is owing 
to the shores of their several rivers having undergone great and 
rapid alteration for this purpose. It is obvious, however, that 
this is not a constant condition of the origin of yellow fever; and 
though many of the places which are peculiarly subject to this 
disease have a sea-coast which is loaded with alluvial mud, yet 
in many others where it occurs there is nothing presented but a 
firm rocky shore. The same objection may be made to many 
other statements of its origin, as the principle of vegetation, the 
elementary decomposition of vegetable substances, damaged cof- 
fee, &c. Dr. Wilson (in his Memoir, published in 1827), endea- 
voured to show that this disease is caused by the gaseous product 
neither of vegetable nor herbaceous matter, but of trees, shrubs, 
or of any sort of wood in a state of decomposition. This view he 
has very ingeniously applied both to its occurrence at sea and on 
shore. Dr. Wilson, to say the least of it, has placed his different 
facts and arguments in an order so clear and forcible, that his 
theory assumes on the whole an imposing and persuasive aspect. 
Its occurrence in the Caribbean Islands and other places, where 
there is apparently a difficulty on these grounds of accounting for 
it, he attributes to a specific decomposition taking place amidst 
the vast coral reefs, which, from their texture being porous, loose, 
and traversed with crevices, form at all times a never-failing re- 
ceptacle for every species of decayed wood, leaves, &c. In other 
places he thinks the mangoe tree in a state of decay is the imme- 
diate source of the peculiar exhalation. 

The origin and progress of yellow fever on shipboard have ever 
been a perplexing point. In accordance with his theory, Dr. 
Wilson accounts for it by supposing, that the wood forming the 
interior of the holds of ships undergoes, in tropical climates, a 
great change, during which some of its constituent principles suf- 
fer decomposition, and pass off in a gaseous form. This change 
is manifested by the wood becoming dark ; by its shrinking and 
becoming denser in structure, and at the same time losing weight; 
in short by seeming to be partly charred. The extent to which 
this process is carried, and the nature of its results, are modified 
by the previous condition of the wood, by the degree of heat, and 
probably by the interior arrangements of individual ships. In a 
vessel newly built, arriving in the West Indies in the hottest sea- 
son of the year, remaining for weeks in harbour, with the hold 
cleared and heated by stoves, the process is speedily completed. 
According to Dr. Wilson, fever in such circumstances appears 
early and spreads rapidly ; but when once it ceases, it does not 
again return. In a vessel, on the contrary, which arrives in the 
cool season, is much at sea, and its hold not dried by stoves, the 
process of decomposition is slow and imperfect, and may never 
be completed. In such a vessel, fever will never be severe and 



causes. 359 

very fatal, but it will often recur and produce sickliness and death 
till the last day of its continuance on the station. 

Amiel says that it appears evident to him that the occurrence 
of the yellow fever epidemics is the result of atmospherical vitia- 
tion, from the fact of the disease having been constantly influenced 
by atmospheric circumstances. They have a fixed period for their 
appearance, a fixed period in which they attain their maximum 
mortality, and a fixed period for their termination. Dr. Craigie 
says, the only mode in which he conceives all these discordant 
statements can be reconciled, is by supposing yellow fever to be 
a disease proceeding not from the influence of terrestrial mias- 
mata, or mere local peculiarities alone, but from atmospheric 
peculiarities entirely; which, however, operate much more directly 
and forcibly in situations favourable to the production of terres- 
trial emanations. While ague is the offspring of the marsh and 
its margins, and remittent is the effect of a more concentrated form 
of the same exhalation from any moist surface in the process of 
solar desiccation, yellow fever appears to be the exclusive product 
of that state of the atmosphere which takes place after a long con- 
tinuance of solar heat with little or no wind, in those points chiefly 
where the atmosphere of the sea and that of the land are in con- 
stant communication and interchange. 

Those who entertain the view, that yellow fever is a contagious 
disease, are divided in their opinions, the one party holding that 
it is at all times essentially and absolutely the result of contagion; 
that it differs entirely from endemic fever ; never proceeds from 
it, and never passes into it. The other party entertain the view, 
that the same causes which produce endemic fever may, by the 
superaddition of a contagious property generated in the subjects 
of the disease, give rise to another form propagated only by con- 
tagion. Dr. Stevens, who advocates the former view, says, that 
in the African typhus, as well as in that new disease, the dandy 
fever, we must either shut our eyes against the most positive 
evidence, or admit that contagion is the sole cause of both these 
fevers ; the proofs of this which he has witnessed are, to his mind, 
just as strong as those in favour of the contagious character of 
either small-pox, scarlatina, or any other disease acknowledged 
to be contagious. A host of evidence may, however, be pro- 
duced against these views ; but as the facts and arguments are 
much the same as those which have been detailed as bearing 
upon the question of contagion in Plague, it is unnecessary to 
enter fully upon the subject here. We must not, however, pass 
over some of the observations which have been made by Dr. 
Chervin, who has, for years, most industriously and strenuously 
opposed the doctrine of contagion as applied to yellow fever in 
particular. After showing that the statements which are made 
of the importation of yellow fever into Barbadoes by the ship 



360 , YELLOW FEVER. 

Hankey, which are particularly dwelt upon by Chisholm as evi- 
dence of contagion,' are anything but correct or conclusive; and 
after having generally exposed the weakness and insufficiency of 
the facts and arguments of the contagionists, he adduces the fol- 
lowing reasons for the conclusion, that yellow fever is not con- 
tagious: — 1. Although it has been the constant practice of the 
inhabitants of towns in the United States to flee to the country as 
soon as the disease appears, and for those who are attacked to be 
conveyed to the abodes of their families, yet in no instance has 
the yellow fever been propagated out of the towns, or in the inte- 
rior of the country thus communicated with. 2. That in hospitals 
devoted to yellow fever patients, the attendants of every class 
have been invariably exempt from the disease, when these estab- 
lishments are situated beyond the source of the sickness, and if 
the attendants did not expose themselves to it. 3. That though, 
according to the hypothesis of contagion, it might be imagined 
that persons frequently approaching patients within the range of 
infection are more liable to contract the disease than those at a 
distance, and not communicating with them, yet this is not the 
case. 4. That in fact the nearest communication with the bodies 
of the diseased, the inoculating with the blood of persons so 
affected, the drinking the black vomit, &c, have not propagated 
the disease. 5. That the apparel used by patients has appeared 
to be equally inoffensive as their persons and corpses ; and that 
separation and seclusion of the healthy from the sick, and the 
prohibition of all intercourse, direct or indirect, have entirely failed 
in preventing its occurrence. 

In order to prove the agency of contagion, a condition is abso- 
lutely necessary, which hitherto has never been properly attended 
to, viz., that the persons to whom the disease has been supposed 
to be communicable, should not reside in the same situation or 
locality as those by whom it is believed to be communicated, as 
in such case their being subject to the same influences as those 
already diseased, entirely invalidates any argument that may be 
offered in support of the operation of contagion. 

[As a proof that yellow fever is not disseminated by a conta- 
gious principle, Dr. Imray relates the following circumstance : — 
"On the 13th December, 1844, the detachment of the 46th regi- 
ment in garrison [at Dominica] was replaced by a company of 
the 71st from Grenada, that island, at the time of their departure, 
being healthy. On the 27th December another company of the 
71st was disembarked from the mail steamer, and marched to 
Morne Bruce, — the passage by steam from Grenada being about 
thirty hours. Shortly after the first company left Grenada, yel- 
low fever broke out in the garrison there, and was prevailing at 
the time the second company left. Two men were taken away 
ill, who, on landing, were carried to the garrison hospital. [Both 



CAUSES. 361 

died with black vomit.] After several days had elapsed new- 
cases were admitted to the hospital, and the disease continued to 
prevail with great mortality, being, however, confined, with two 
exceptions, to the company by whom it was imported. During 
this time there was no interruption to the usual intercourse be- 
tween the town and garrison. The non-contagious nature of the 
fever was rendered still more certain by the removal of the troops 
from Morne Bruce to a level spot of ground in the environs, and 
no precaution was taken to prevent constant communication with 
the inhabitants."* These circumstances show that malignant 
yellow fever may be introduced into a country, and not extend 
beyond the parties coming from the affected localities. Yellow 
fever had been prevailing for some time at New Orleans, when 
it appeared at Galveston, and there is much intercourse between 
the places. On the other hand, what Dr. Smith considers the 
local causes of the disease were very abundant about the limited 
district—the strand — to which the infection was confined. There 
were animal and vegetable matters abounding around the houses, 
and a marsh exposed to the heat of the sun, when the tempera- 
ture ranged daily in the shade from 84° to S9°. Patients were 
removed from the infected district to the healthy sections of the 
city without communicating the disease to their attendants, or 
the inmates in their new abode ; these sections retained through- 
out the epidemic their healthfulness. Of the medical men of the 
place two only were attacked, and they alone dwelt in the in- 
fected district. Dr. Smith performed many dissections, examin- 
ing everything closely, and immersing his hands freely in black 
vomit, &c, with perfect impunity. He tasted black vomit re- 
peatedly, when fresh ejected from the stomach of the living, with 
equal impunity. He says : — "After a careful observation of the 
history of the epidemic, no fact has come to light to show that 
the disease was contagious, that is, communicable from a person 
labouring under it to one in health, but that it is contracted only 
by exposure in the infected districts."! 

Dr. Nott says, that in Mobile no one, in or out of the profession, 
believes in its transmissibility, and that the town is peculiarly well 
situated for investigating this point. 

To the question, " If yellow fever ever prevails sporadically," 
Dr. Louis, after a careful analysis of forty-five cases — nineteen of 
which were fatal, and 26 of which recovered, and which occurred 
at various periods when no epidemic was prevailing — answers the 
question in the affirmative, so far as Gibraltar is concerned. This 
point being settled, its non-contagiousness would not follow, as 
we every day see the most incontestably contagious diseases, as 

* [Ed. Med. and Surg. Journ., Oct., 1845, pp. 338, 339.] 
f [Smith, loc. cit., p. 33.] 



362 



YELLOW FE.VER. 



small-pox, under sporadic forms, and appearing only at distant 
intervals of time.] 

In the absence of such satisfactory evidence in its favour, we think 
that, amid all the conflicting histories of the etiology of this dis- 
ease, we are justified in stating the following to be fair conclusions 
in respect to its origin. — 1. That yellow fever is not contagious, 
either primarily or contingently ; 2. That it is essentially and 
solely of endemic origin ; 3. That it is difficult to state decidedly 
what are the local causes which produce it : but most probably 
they are atmospherical : and as the disease is found only to occur 
on or near to the sea-shore, that most probably a climate which 
is modified by the sea forms a necessary condition. 

The only satisfactory way of ascertaining what local and essen- 
tial conditions are necessary to produce yellow fever, would be 
to investigate in such places where it is usually endemic, as at 
Vera Cruz, the west coast of Africa, &c, what those peculiar 
states are, both in respect to climate, physiognomy, &c., which do 
not obtain in other places in the immediate neighbourhood, and 
where the disease does not occur. This, however, cannot be 
expected to be accomplished, until medical topography has been 
more carefully and extensively attended to than has hitherto been 
the case. 

Though the predisposing' causes of yellow fever are very 
numerous, a few words only are necessary. That which re- 
quires most particular mention is, the powerful influence exer- 
cised by the coming of a stranger uninitiated to the climate where 
it occurs endemically. Beside this may be enumerated the ordi- 
nary causes which in other places predispose to fever generally, 
such as intemperance, excessive venery, prolonged study, manual 
labour under circumstances of great fatigue, especially if carried 
on in the heat of the sun, checked perspiration, sleeping exposed 
to the night dews. From what has just been said upon the 
causes of this fever, it may be well understood that we should 
not be inclined to estimate amongst its preventives the system 
of separation entailed by the quarantine laws with their train of 
hardships and inconveniences. The means of prevention consist 
rather in retiring, on the occurrence of yellow fever in an epi- 
demic form, to the neighbouring high lands, or to some distance 
inland ; in ventilating the houses, and in avoiding the predis- 
posing causes of fever generally. Mr. Wallace says, that one 
essential point is to preserve, as far as we can, the natural energy 
of the system ; which is best done by giving to the body regular 
sleep, adequate exercise, a moderately nourishing diet, and to the 
mind a proper degree of recreation and employment. As> much 
as possible, means should also be taken to protect the system 
from the morbid influence of the atmosphere, by being within 
doors by nightfall, by keeping the windows closed during the 



TREATMENT. 363 

night, and by having fires in the rooms so as to prevent a stag- 
nation of air. Experience has shown, that very little reliance is 
to be placed upon the disinfecting mixtures that have been pro- 
posed with the view of altering the constitution of the atmo- 
sphere, and by this means destroying the malaria which may 
exist in it. 



VIII. TREATMENT. 

From a review of the symptoms, the indications of treatment 
are, 1st. To subdue the inflammatory and irritative state of the 
system ; and if possible, to prevent the supervention of local con- 
gestion or inflammation. 2. To prevent the system sinking into 
a state of collapse. 3. When the inflammatory state is subdued, 
to sustain the powers of the system. The modes that have been 
suggested to carry out these may be resolved into, 1, The anti- 
phlogistic, which is by bleeding, both general and local, purging, 
&c. 2. The mercurial, (which, in some measure, is a branch of 
the first,) in which the chief reliance is to be placed upon ptya- 
lism induced by the free administration of mercury. 3. The 
stimulating, in which bark, port wine, &c, are freely employed. 
4. A plan of treatment in which all these modes are conjoined, 
ptyalism in addition to the antiphlogistic being first resorted to, 
and followed by the stimulating. This mixed treatment is founded 
upon the view, that yellow fever is primarily an inflammatory 
disease, becoming putrid in its progress. 

1. Dr. Rush, who particularly condemns the two latter modes 
of treatment, is one of the most strenuous advocates for the anti- 
phlogistic, recommending that it should be pursued to a very 
vigorous extent, When speaking of blood-letting, he says, that 
though in some cases moderate bleedings may be sufficient, yet, 
that generally it is required to be done very often, and to the 
abstraction of large quantities. Moseley says, that the intention 
of bleeding can be answered only by performing it immediately, 
and in the most extensive manner, which the high state of in- 
flammation and the rapid progress of the disease demand: taking 
away only six or eight ounces of blood, because the patient may 
be faint, which is a symptom of the disease, is doing nothing 
towards a cure. Bleeding must be immediately performed and 
repeated every six or eight hours, or whenever the exacerbations 
come on, while the heat, fullness of pulse, and pains continue ; 
and if these symptoms be violent and obstinate, and do not abate 
during the first thirty-six or forty-eight hours of the fever, bleed- 
ing must be executed usque ad animi deliquium. Bancroft 
thinks, that in order to avoid the mischiefs arising from the super- 
added violence of the disease, no means are so certain or bene- 



364 



YELLOW FEVER. 



ficial as bleeding ; but that it may prove advantageous, it ought 
to be performed copiously, and from a large orifice, as early as 
possible after the inflammatory action is developed. Jackson 
also adds his testimony, that the abstraction of blood in large 
quantities is a most decisive process. Dr. Hector M'Lean says, 
that his experience confirmed its utility, and that his practice was 
much more successful after he had adopted blood-letting than 
before. He is not, however, an advocate for its employment 
after the first or second day ; after the third, he decidedly con- 
demns it. Sir W. Burnet became so convinced of the absolute 
necessity of the free abstraction of blood, that he issued orders 
to the surgeons of the fleet, when stationed in the Mediterranean, 
to the effect, that they should pursue this practice in every case 
of yellow fever that came under their inspection. He recom- 
mends it to be employed both generally and locally, in order to 
remove the affection of the brain ; on accomplishing which, he 
says, depends all subsequent success, and which being removed, 
generally prevents the dangerous symptoms of the after stages. 
These operations, he adds, must be repeated according to the 
urgency of the symptoms ; and though it will often happen, after 
a few ounces of blood have flowed, that syncope is induced, yet 
this must not prevent the repetition of the bleeding : in the course 
of an hour the blood-letting may generally be repeated, and thirty 
or forty ounces taken away without producing it. He further 
says, that blood has often been taken to the amount of 130 or 
140 ounces, and even as far as 200, with the most marked advan- 
tage. On the other hand we find nearly all the practitioners in 
the West Indies, and many of the American and Spanish phy- 
sicians, condemning the use of the lancet as strongly as those just 
mentioned have recommended it. But as their opinions merely 
amount to a denial of its efficacy, or to some strong statement, 
that those who may pursue such a practice are " guilty of nothing 
short of murder," or " are chargeable with their patient's death," 
we shall not particularly dwell upon them. It appears evident, 
however, from the experience of Chisholm, Townsend, Mus- 
grave, Amiel, and others, that blood-letting carried to any very 
great extent, or after the first inflammatory stage of the fever has 
subsided, is decidedly injurious. Though it may be very bene- 
ficially pursued on the first commencing of the disease, its repeti- 
tion in all cases is, to say the least of it, hazardous. 

Mr. Wallace has placed the whole subject in a fair and judi- 
cious point of view, when he says that, as a general rule, blood- 
letting is inadmissible ; but that to this rule there may be many 
exceptions. If the- patient be decidedly labouring under inflam- 
matory disease ; if the arteries are beating strongly, with the skin 
parched and burning, the headache acute, and all or the chief of 
those symptoms which constitute synochal fever be present, there 



TREATMENT. 365 

cannot be a doubt as to the propriety of having immediate recourse 
to blood-letting. (Edin. Med. Surg. Joitrn., vol. xlvi.) There is 
indeed no other remedy to which we can look, in such cases, for 
anything like immediate and decided advantage ; and therefore it 
is indispensably necessary, not only to have recourse to it early, 
but to carry it to the requisite extent. It will not do to measure 
the quantity of blood, or to settle beforehand the number of ounces 
we may with propriety take away ; but we are to look to the cha- 
racter of the disease and to the strength of the patient ; and so long 
as the latter will bear further reduction, and the former is evi- 
dently continuing its course, so long will it be necessary for us to 
proceed with the remedy. But supposing the fever to have a 
somewhat different character; the pulse, though tolerably full, to 
be easily compressed ; the heat of surface moderate ; the headache 
accompanied with a slight degree of stupor, with that degree of 
anxiety which indicates as much of nervous as of vascular de- 
rangement, then, although blood-letting may still be admissible, 
nay, perhaps indispensable, it is necessary to weigh carefully 
these two very important questions : — 1. Whether general blood- 
letting ought to be had recourse to at all ? and, 2. To what extent 
it should be carried ? And again, if the disease have still a different 
character; if the strength of the artery, instead of being increased, 
be diminished ; the surface cold and slightly clammy ; the patient 
nearly heedless of what is passing around him; and all the ener- 
gies, mental and corporeal, depressed in an extraordinary degree, 
under such circumstances, if blood-letting be not altogether pro- 
scribed, it will at least be but seldom admissible : and, indeed, 
nature herself, by obstinately refusing to yield the blood, often at 
once points out the impropriety of the practice, and effectually pre- 
vents its being carried into effect. In addition to general bleeding, 
if there be any very prominent symptoms of local congestion or 
inflammation, topical bleeding may be resorted to. Depletion 
by leeches or cupping has been found materially to contribute 
towards relieving headache and checking the incipient gastric 
symptoms. 

[Yellow fever assumes diverse types in various years, and in 
different latitudes. Dr. Nott witnessed five epidemics of yellow 
fever at Mobile,— 1837, 1839, 1842, 1843, 1845,— each of which 
presented some predominant peculiarity of type, and all demanded 
some modification of treatment. This may account for the oppo- 
site opinions expressed with regard to the treatment of this dis- 
ease, and more particularly of the advantages of blood-letting. 

" The symptoms," observes Dr. Imray, " in appearance, may 
be much the same, yet, in different countries, situations and sea- 
sons, different remedial measures are required, and no one plan 
of treatment has yet been discovered that can be considered 
applicable in every instance. We have an example of this in the 



366 YELLOW FEVER. 

two islands of Martinique and Dominica, both mountainous, 
similar in geographical formation, with the same temperature 
and climate, and separated by a channel scarcely thirty miles in 
breadth ; yet we find the epidemic yellow fever in the one island 
successfully treated by blood-letting,* while in the other the same 
treatment was followed by opposite effects. ***** Though 
fairly tried by the civil practitioners, as well as the military medi- 
cal officers, it was found, as a general plan of treatment, not to 
succeed. Assistant-surgeon Mlllingen found, that in very few 
cases was bleeding admissible. It only tended to bring on sooner 
that debility which supervened so early, and diminished the pros- 
pect of the patient's recovery."! 

Dr. Nott lays it down as a general rule, that yellow fever is 
not a disease which demands active depletion; that cases demand- 
ing the use of the lancet are rare at Mobile. " When/' he says, 
" the pulse is full and strong, and is decidedly above par, the 
lancet should be used promptly and boldly to guard against the 
production of local lesions, but we should at the same time bear 
in mind that this stage is of short duration ; that we are dealing 
with a specific disease, which has a strong tendency to early col- 
lapse, and we soon may have need for all the strength that we 
take away.";}: 

Dr. Dickson observes, with his usual judgment :— " I repeat, 
then, that while I propose to you no speculative objections against 
the lancet, and admit that circumstances may call for its occa- 
sional employment, the results of experience and observation are 
unfavourable to the general or frequent resort to it. * * * From 
all this you will not fail to perceive, at least, the necessity of due 
caution and prudence in the use of the lancet. It is available 
only in the first stage of the disease, which rarely affords oppor- 
tunity for its repetition. If you determine to resort to it, place 
your patient half erect, make a large orifice, and draw from the 
vein at once a sufficient amount to make a forcible impression on 
the system. You will thus fulfil your purpose of the reduction 
of vascular excitement with the least absolute diminution of the 
original powers of action and resistance of the constitution. "§] 

In addition to blood-letting thus judiciously employed, the ex- 
hibition of purgative medicines has been very generally approved. 
Nevertheless, there has been some contrariety of opinion expressed 
as to their selection. Rush and some others have administered 
them to a very great extent, in doses, for instance, of fifteen grains 
of jalap and ten of calomel, every two or three hours. Hillary, 

* [Catel and Rufz both employed blood-letting largely, the former to syn- 
cope.] 
f [Ed. Med. and Surg. Journal, October, 1845, p. 328 ] 
t [Am. Journ. Med. Sciences, April, 1845, p. 293.] 
§ [Dickson's Practice of Physic, vol. i , p. 360.] 



TREATMENT. 367 

Hume, and Cleney, who do not approve of this severe treatment, 
recommend the administering of much milder medicines, such as 
manna with cream of tartar, sulphate of potash, rhubarb, &c. [In 
an infusion of senna and rhubarb in which manna had been dis- 
solved, Dr. Smith found a purgative which unloaded the aliment- 
ary canal without irritating the mucous membrane.] Dr. Ban- 
croft, who states that it is particularly necessary to obviate the 
tendency to accumulation of the alimentary contents, as they are 
in great measure the source of the morbid irritability of the whole 
intestinal canal, and more especially of the stomach, recommends 
that such medicines should be employed as will not offend and 
irritate the stomach by their bulk or quality. There can be no 
doubt that, when this organ is not in a state of too great irrita- 
bility, the administration of mild but efficient purgatives is of the 
most essential service; it is, in fact, a practice which should by 
no means be omitted. As there is very often, however, so much 
irritability of the stomach as to render it almost impossible for 
any of the purgatives in ordinary use to be retained, the previous 
administration of small doses of opium, or the combination of 
opium with the purgative, should be resorted to ; and in case of 
their not succeeding, warm emollient and purgative clysters 
should be freely administered, until free evacuation of the bowels 
be procured, after which irritation of the stomach is generally 
allayed. Mr. Tegart has the merit of proposing the exhibition 
of the croton oil, not only in these cases of excessive irritability, 
but generally. He says, that a drop or two placed upon the 
tongue almost immediately excites the bowels to action, without 
adding to the irritability of the stomach. Mr. Hacket, who 
attributes much of the success of his practice at Trinidad to the 
use of this medicine, both by mouth and by clyster, says that the 
power which it has of allaying gastric irritability and general 
nervous excitement, as well as restoring the circulation to the 
surface, and thus relieving the internal congestion, is extraordi- 
nary ; and though it may seem, for the moment, when first given, 
to increase the irritability, yet, after a little time, it hardly ever 
fails to produce the desired end. 

The prompt administration of emetics has by many been 
strongly recommended, but more especially by Arejula, one of 
the first authorities in the treatment of yellow fever. They are 
condemned, however, by most practitioners, and we think with 
justice; for, as Bancroft observes, in place of allaying nausea 
they have rather a tendency to excite the irritability of the sto- 
mach, which we have just shown is an object particularly to be 
subdued and guarded against. 

Cold affusion has been recommended. Some, indeed, state, that 
if employed on the first commencement of the disease, it very 
frequently succeeds in cutting it short entirely. Without, how- 



368 



YELLOW FEVER. 



ever, anticipating so happy a result, there can be no doubt that 
this remedy, judiciously applied, is most salutary. Its immediate 
effect appears to be that of lowering the temperature, soothing 
the general irritability, inducing sleep, and recruiting the powers. 
Should the disease, however, have passed into a stage of collapse, 
this remedy, unless carefully employed, may be attended by 
very unpleasant results. Under such circumstances, aspersion, or 
slight sponging, may be resorted to, administering, at the same 
time, nourishment and cordials. The general rule to be observed 
in the use of cold bathing is, that it be resorted to as long as 
the heat of the body is above the natural standard; and that 
when the temperature is depressed, it should be omitted. Under 
some circumstances the warm bath has been also recommended ; 
and Jackson has combined its employment with the use of the 
cold affusion. According to the experience of most practitioners, 
this treatment is followed by very questionable success. 

In addition to the antiphlogistic means above detailed, the use 
of diaphoretics has been much recommended. Among these 
the acetate of ammonia, James' powder, Dover's powder, &c, 
have been particularly employed. Drinking small quantities of 
cold water has also been particularly advised : a liberal use of it 
has been found not only to determine to the skin, but to mode- 
rate the heat of the surface, as well as to allay the general febrile 
state. Dr. Bancroft, though approving of this administration 
of cold water, and speaking of its effects, is yet opposed to the 
exhibition of the medicines that act upon the skin. He says, that 
though they have been frequently employed in the treatment of 
yellow fever, yet he cannot join in their commendation, because 
they tend to increase that disposition to vomit, from which the 
greatest danger is always to be apprehended ; and that of this 
class none are so detrimental as the preparations of antimony, for 
they usually leave behind them an extreme degree of irritability 
in the prima? vise, which too often resists all our endeavours to 
control it. In addition to the above means, the advocates of the 
antiphlogistic plan recommend the occasional use of epispastics 
and blisters: they have been recommended with the view of 
being useful as general and local revulsives, and it is on this prin- 
ciple that Dr. Linton has suggested their application to the spine, 
which has been often found to allay, very singularly, the irritation 
of the stomach. Dr. Gillkrest suggests, in the hope of afford- 
ing some palliation of the incessant vomiting, often so very dis- 
tressing in yellow fever, the use of dry cupping on the epigas- 
trium, as practised by ancient physicians in their endeavour to 
relieve the vomiting in malignant cholera. 

2. The mercurial treatment has had its warm advocates as 
well as opposers. Chisholm, after thirty years employment of 
it, views it as a sheet anchor, but thinks that salivation is a ne- 



TREATMENT. 369 

cessary condition. This is likewise the opinion of Dr. Rush and 
many others. Many have also recommended in addition to the 
free internal administration of this remedy, that its effect should 
be accelerated by its external application. Bancroft, Dalmas, 
Stephens, and many others, do not, however, entirely approve of 
this pracfice. The former says, that previous doubts as to its effi- 
cacy have not been removed by subsequent experience ; and that, 
at any rate, it appears certain, the good effects of the mercurial 
treatment have been greatly exaggerated ; at the same time he 
cannot go quite so far as Dr. Grant, who avers that, although 
he has been called in to attend many under such circumstances, 
not one survived, and that they became victims to the mercury 
rather than to the fever. We think Dr. Bancroft's observations 
on the use of the mercurial frictions very just: he says that they 
do not seem likely to prove altogether innocent in those cases in 
which they may happen to do no good ; for, besides the salivation 
which they may produce, when the patient lives long enough, and 
which is to be added to the number of his sufferings already 
sufficiently abundant, the very act of rubbing on the mercury 
tends greatly to disturb both body and mind when his only wish 
is to remain unmolested : while the covering a large portion of 
the skin with a greasy ointment, produces a considerable accumu- 
lation of heat therein, by which the general temperature of the 
body, and with it many of the other febrile symptoms, may be 
increased. There can, however, be no doubt, that the adminis- 
tration of mercury, except in the mildest cases, which will be 
found to give way to more gentle and simple means, is often 
attended by beneficial results ; but at the same time the propriety 
of invariably pushing its exhibition to a state of salivation may 
be very much questioned ; we are inclined to think, the chances 
of recovery, under such circumstances, would be rather dimin- 
ished than otherwise, especially if collapse should intervene. 

3. Though the mode of treatment by stimulating and tonic 
medicines has found some advocates, it has been so almost uni- 
versally condemned, that Dr. Gillkrest is fully justified in say- 
ing, it seems quite impossible to explain how, up to the time of 
his death, large doses of the bark should have merited the special 
favour of Dr. Lafuente, one of the principal physicians con- 
nected with the epidemics of Andalusia, during some of the first 
years of the present century. 

[It has been the practice, within a few years, in some of the 
southern and south-western states, to give very large doses of 
the sulphate of quinine from the commencement of the disease. 
A scruple to a drachm was often administered at a single dose. 
What success has attended this plan of treatment, the writer has 
been unable to ascertain with any degree of certainty. Dr. Imray 
states that " the sulphate of quinine was sometimes exhibited 
24 



370 YELLOW FEVER. 

when the stage of excitement had subsided, but it did not appear 
to exert any influence in preventing the usual train of symptoms 
which preceded death/'] 

4. After a careful review of ail that is known on the nature of 
Yellow Fever, it appears that the treatment which compre- 
hends the occasional application of the above plans, modified by 
the symptoms which arise during the progress of the disease, is 
not only the most philosophical, but has proved by experience to 
be the most successful. 

Before concluding, we may mention that a variety of remedies, 
as opium, ether, limewater, &c, have been applauded by some 
as exceedingly efficacious, and by others condemned as injurious 
in the extreme. The discussion of the relative merits of these, 
however, would occupy the time of the reader unprofitably ; we 
forbear entering upon the subject : we must not, however, omit 
to mention the plan of treatment which has been specially recom- 
mended by Dr. Stevens. His theory of the nature of yellow 
fever has already been alluded to. Upon this he founds a system 
of treatment which consists in the free administration of saline 
medicines. He says, that when proper saline remedies (by which 
he means those which are not purgative) are used, they do not 
fret the stomach ; they act on the intestines as much as is neces- 
sary ; they keep up all the secretions, particularly that of the 
kidneys; and enough is absorbed to enter the circulation and 
prevent the dissolution of the blood, and preserve it until the fever 
abates and all the danger is past. 

[The general plan of treatment adopted by Dr. Imray in the 
Dominica epidemic of 1843, is thus described by him. "The 
bowels were freely acted on by purgatives, warm baths were 
applied according to the symptoms, and saline medicines admin- 
istered. When the surface was hot and dry, free perspiration 
was procured if possible. Local symptoms were treated by 
topical blood-letting, blisters, &c. The application of cold to the 
head, particularly by affusion, was as useful in controlling in- 
creased cerebral action, as pleasing to the feelings of the patient. 
Calomel was administered chiefly as a purgative, and was not 
given in large and repeated doses with the purpose of affecting 
the system, having formerly been found rather injurious than 
useful when exhibited with this view. Mr. Milligen used the 
chloride of soda in the military hospital with happy effects, 
where bleeding from the gums had taken place. It was admin- 
istered in injections as well as by the mouth. " 

The treatment adopted by Dr. Ashbel Smith, in the Galves- 
ton epidemic, consisted of blood-letting employed, as soon as the 
excitement was fairly developed, till slight faintness was pro- 
duced; hot and strong mustard baths were applied to the feet and 
legs; the patient was placed in bed, and sedulously guarded against 



TREATMENT. 371 

any current of cold air, which might repel the blood from the sur- 
face; and the cathartic administered until its operation was pro- 
duced. After this no other medicine was required in the stage of 
excitement, but the hot mustard bath was repeated twice or thrice 
in the twenty-four hours, as a means of sustaining a continued glow 
on the surface, whilst a little tamarind water or sage tea was al- 
lowed as a beverage. If, after the abatement of the excitement, 
the, extremities became cool, the hot mustard bath was promptly 
resorted to, and nausea and vomiting occurring, were allayed 
with black drop or laudanum. Opiates in the advanced stage 
were very useful, and appeared to save some who were rapidly 
sinking. 

One point seems conceded by all,— that it is only at the com- 
mencement that treatment can be of much avail. Dr. Imray re- 
marks that " the efficacy of early remedial measures was clearly 
shown in the military hospital, in the difference of mortality in 
those who came early to the hospital, and those who came later."] 



372 



CHAPTER VI. 

INTERMITTENT FEVER. 

[Syn. — AitfXE<ffo»jTS? tfyfsrot, Hippocrates; Anetus, Good & Young; Febris inter- 
mittens; Ague, Paludal Fever, Ague and Fever ; Fievre intermittente, F. d'acces, 
F. des marais, F. periodique, Fr.; Kalte fieber, Wechselfieber, Aussetzende fieber, 
Germ.] 

Intermittent Fever is so called from a very marked series 
of phenomena which take place during its progress. The chief 
characteristic is, that a paroxysm of fever is followed by a cessa- 
tion of all febrile symptoms, which apyrexial period usually lasts 
during a well-defined period, and is very constant, though differ- 
ing in duration in the various forms of this disease. The defini- 
tions which various authors have adopted are all founded on this 
peculiarity. Dr. Cullen describes intermittents as "fevers arising 
from marsh miasmata, consisting of many paroxysms, without 
fever, or at least with evident remission, returning with remark- 
able exacerbation, and in general with shivering, one paroxysm 
only taking place each day." This definition is far from being 
unobjectionable : that of Dr. Eberle is both more comprehensive 
and succinct, its generic character, according to this writer, con- 
sisting in " a succession of periodical paroxysms of fever, each 
paroxysm commencing with chills and terminating in free perspi- 
ration, with protracted intervals of perfect freedom from fever." 
(Practice of Medicine, p. 59.) 



I. PREMONITORY STAGE. 

Fever, in the various forms in which it ordinarily occurs, is 
almost always preceded by a condition known as the premonitory 
or forming stage ; this includes the period intervening between the 
first deviation from health and the commencement of the febrile 
paroxysm. It has been stated by some observers, that this ante- 
cedent stage does not precede intermittent fever. Most writers, 
however, describe s it; and there can be no doubt, though it may 
not always occur, that it yet happens sufficiently often to justify 
its being considered as a part of that derangement from healthy 
action, which is consequent upon the accession of this disease. 
The symptoms which characterize this stage are not uniformly 
very definite. They are illustrative of that state which may be 



SYMPTOMS. 373 

termed febricula. The patient feels tired, complains of slight 
headache and aching pains in the loins, and perhaps in his limbs 
generally, frequently with fits of yawning and stretching. The 
functions of the stomach are impaired, evinced by loss of appetite, 
flatulence, and constant thirst. The pulse is frequent, the skin 
is hot and dry, the urine high-coloured, depositing on cooling 
a red sediment, and the fecal discharges are dark-coloured and 
offensive. This state lasts in some cases for a day or two, in 
others extends to a period of ten days or a fortnight, there being 
usually a marked increase of the symptoms about midday. They 
eventually terminate in a rigor, which is the commencement of 
that series of phenomena which constitute the paroxysm of inter- 
mittent fever. This premonitory stage does not, however, appear 
in the intermittent type to follow the same laws in reference to 
the fever itself as is observed in the continued forms: in these lat- 
ter the shorter the premonitory stage the more violent is the fever, 
while in intermittents the reverse is usually the case. This may 
probably depend on a difference in the nature and intensity of the 
remote febrific cause, or on the powers of reaction being very dif- 
ferent in these several diseases. 

When the premonitory stage has been superseded by the cha- 
racteristic symptoms of intermittent fever, a new series of phe- 
nomena takes place : these are a paroxysm of fever alternating 
with a period of intermittence. 



II. SYMPTOMS OF THE PAROXYSM. 

The paroxysm of fever consists of three well-marked stages : 
— 1. The cold; 2. The hot; 3. The sweating. 

1. The cold stage is first ushered in by a sensation of some 
slight chilliness, with feelings of languor and long fits of yawn- 
ing, which render the patient sensible of the febrile accession 
before it is suspected by others. The toes and last joints of the 
fingers lose their temperature and feel benumbed, and the nails 
have a bluish cast. This early period of the paroxysm is some- 
times attended by pains in the back and loins, sometimes by 
headache and even stupor. The cold stage may now be said to 
have fairly set in : the patient is weary and restless, and com- 
plains of diffused aching pains ; the ideas crowd rapidly on the 
mind, and the attention is with difficulty fixed ; there is much 
oppression about the praecordia, with a squeamishness of sto- 
mach ; the sensation of chilliness increases, and is experienced in 
defined lines, as if small streams of water were trickling down 
the back, shoulders, chest, and abdomen, until the coldness per- 
vades the whole frame : these feelings at length become so real 
and intense that the patient buries himself beneath the bed-clothes, 



374 INTERMITTENT FEVER. 

and craves for warm drinks; the teeth chatter, the limbs shake, 
and in fact the whole frame participates in the general commo- 
tion, for the internal as well as the external organs are affected 
by the tremor. During the continuance of the rigor, as these 
symptoms are technically called, the patient complains of fatigue, 
the muscular strength being gradually exhausted, the sensibility 
of the surface diminished, the expression of the countenance 
pinched, the features shrunk and pale, the eye dull, sunk, and 
hollow, and the cheeks and lips livid and collapsed. The skin 
generally becomes pale and assumes a rough appearance, not 
unlike that condition which is termed "goose skin;" in many 
cases so contracted, that rings previously tight drop from the 
fingers, and tumours on the surface, if they exist, become shriv- 
eled. The pulse is small, contracted, and firm, generally quick, 
but sometimes slow and occasionally intermitting; the tremor 
artuum, however, interferes much with a just appreciation of 
the precise number of its pulsations. The respiration is hurried, 
anxious and oppressed, attended by a sense of weight, tightness, 
and incapability of taking a deep inspiration, frequent sighing, 
and not unfrequently by a short dry cough. The head aches ; 
the mind is embarrassed, dejected and confused ; and the patient 
is quite incapable of fixing the attention steadily on any given 
subject; occasionally there is delirium. Dr. Maculloch lays 
much stress upon the presence of a peculiar irritability of mind, 
to which the patient never becomes reconciled, however much he 
may to the other concomitants of the cold stage. He states it to 
be very constant, even in those chronic cases where scarcely any 
other symptoms are very conspicuous, and that it in fact consti- 
tutes at times the sole characteristic of the cold fit. ( On Marsh 
Fever, p. 245.) 

In those of a debilitated constitution, especially if there exist 
any tendency to plethora, a severe attack of the cold stage is 
frequently attended by drowsiness, if not by deep coma; the 
mouth and fauces are dry and clammy, but the tongue is moist ; 
the thirst is urgent and continued ; the urine is copious, clear, 
colourless, and does not deposit a sediment on cooling ; the de- 
jections are dark and bilious. Towards the conclusion of the 
attack nausea supervenes with occasional vomiting ; this some- 
times occurs to a severe extent. Sooner or later, however, the 
chills begin to abate, transient flushes of heat pass over the face 
and body, the chilliness now recedes rapidly, and the heat en- 
croaches, pari passu, until it obtains a complete ascendency. 

Such are the usual symptoms of the cold stage : its duration is 
very various, rarely continuing less than half an hour or more 
than four. It is a fact well worthy of remark, that occasionally 
when the most intense feeling of universal cold is present, though 



SYMPTOMS. 375 

the extremities are chilly, the heat of the body itself is above the 
natural standard. 

2. The hot stage, which is one of reaction, gradually succeeds 
the cold, the one running into the other without evident or dis- 
tinct interval. This stage is characterized by a flushed and turgid 
countenance : the surface of the skin is dry, and its temperature 
raised much above the natural standard ; Fordyce observed it as 
high as 105°, while Mackintosh says that he has seen the ther- 
mometer, the accuracy of which had been well-ascertained, rise 
even in this country to 110°, and that in warm climates it is said 
to rise to 112°. The mouth is dry, the tongue parched, and the 
thirst excessive ; the pulse is full, strong, and free ; the respiration 
hurried and oppressed, though not to the same extent as in the 
cold stage; the urine is scanty, high-coloured, putrifying soon, 
but not depositing a sediment. The patient generally complains 
of acute pain in some part of the body, very often in the forehead 
and lumbar regions, and not unfrequently in the thorax, left 
hypochondrium, and extremities. The whole expression is that 
of restlessness, general uneasiness and oppression about the prae- 
cordia: the senses are acute, unless, as frequently happens, deli- 
rium supervene a short time before the commencement of the 
succeeding stage. The hot stage is more irregular in its duration 
than the cold ; it rarely continues less than three hours or more 
than twelve. 

3. The sweating stage commences in a perspiration, which, 
appearing first on the forehead, breast, arms, and legs, soon be- 
comes general and profuse. No statements have been made by 
the observers of this disease, by which we are enabled to calcu- 
late the quantity of fluid thus excreted, but there is reason to 
believe that it is very considerable. During the course of this 
stage, the pulse, though it continues full, loses its hardness and 
frequency; the breathing becomes free and natural; the urine 
retains its high colour, and deposits a light red lateritious sedi- 
ment; the bowels are more easily acted on; the heat of the skin 
subsides ; the headache and thirst abate ; the appetite returns, and 
there is a gradual subsidence of the febrile symptoms : in fact this 
stage continues until a perfect remission, or state of apyrexia, is 
established. On this taking place the patient is frequently enabled 
immediately to return to his duties as if in full health ; sometimes, 
however, a profound sleep comes on, which may last for some 
hours, when the patient awakens refreshed, and free from lassi- 
tude ; others, however, especially in long standing cases, labour 
under a feeling of excessive weakness. 

The stage of apyrexia, or intermission, though it may be en- 
tirely free from the phenomena understood to be characteristic of 



376 INTERMITTENT FEVER* 

fever, must by no means be regarded as a state of health. Gene- 
rally speaking, the countenance is sufficiently expressive of this, 
having a pale and sickly aspect ; the mental and bodily powers 
are excited only with great effort, and are easily exhausted and 
fatigued, a general languor pervading the system ; the appetite is 
indifferent, and the digestive functions are carried on imperfectly; 
there is also a remarkable sensibility to cold, and a want of power 
to resist its effects, the function of generating and preserving ani- 
mal heat being evidently deficient. 

Such is the ordinary course of the febrile paroxysm, and of 
the period of intermission in an intermittent fever. Independ- 
ently of the differences in the relative duration of each of these, 
and which will afterwards be particularly pointed out, there are 
other peculiarities which require notice : — 

In the cold stage the chills are sometimes very partial, being 
confined to one or more parts of the body : for example, there 
are instances of a single limb being the seat of this stage ; some- 
times again it is so slightly marked as to amount only to the 
slightest sensation of chilliness creeping along the back, and over 
the extremities, or perhaps there may be only severe headache, 
or a lethargic state, or great languor with distressing yawning : 
occasionally the paroxysm is announced by violent articular, 
lumbar, or frontal pains, and sometimes the patient falls into a 
profound sleep for several hours, and awakes in a violent hot 
stage. {Mackintosh's Practice of Physic, vol. i., p. 63.) These 
forms are vulgarly known by the name of the dumb ague: now 
and then a nervous pain of the brow following the course of the 
supra-orbitar nerve, resembling an attack of tic douloureux, takes 
the place of the usual symptoms; and Dr. Eberle has known 
this stage to commence with violent vomiting, and to terminate 
speedily in stupor and partial insensibility. {Op. cit., vol. i., p. 61.) 

In the sweating stage the anomalies are frequently very con- 
spicuous : occasionally the pyrexia may have been very intense 
and prolonged, followed by very slight perspiration, or even only 
a clammy moisture ; sometimes a copious flow of urine, or even 
diarrhoea, appears to supersede every other symptom. These varia- 
tions from the usual course were very frequently observed in those 
who had returned with intermittent fever from the Walcheren ex- 
pedition. {Davis on the Walcheren Fever, p. 19.) Andral men- 
tions the very curious case of a young man who had been hemiplegic 
on one side of his body from infancy, and who was attacked with 
tertian intermittent. He only perspired on that half of the body 
which had not been paralyzed. He stated, however, that in his 
best health he never perspired but on one arm or leg, and on one 
side of his face and neck. Instances of irregularity are also on 
record, in regard to an inversion in the natural order of the cold, 



SYMPTOMS. 377 

hot, and sweating stages ; these, however, are of very rare occur- 
rence. According to Dr. Davis, anomalies were as frequently- 
observed in the intervals. In those who had returned from the 
Walcheren expedition, he observed that the paroxysms often left 
the appetite impaired, the rest disturbed, and frequently induced 
drowsiness approaching to coma, prostration of strength, dejec- 
tion of the spirits, emaciation of the body, irregularity, sometimes 
vitiation or suppressions, of the secretions. In a few instances 
the intermission was protracted for a week or ten days, the 
patient during this time being harassed with visceral obstruction, 
while there was disinclination or inability to exercise the mental 
or bodily faculties. The disease, instead of subsiding, appeared 
only to cease for a moment, in order, when the paroxysms were 
renewed, to attack with greater vigour the internal organs, more 
especially the viscera of the abdomen ; and when inflammation 
supervened in organs previously affected with organic disease, 
the structural lesions were increased, and quickly induced dysen- 
teric affections and ascites. It has occasionally happened that 
patients have been seized, after the paroxysm had passed over, 
with pain in the head, and a confused state of intellect, termi- 
nating two or three days afterwards in complete coma: sometimes 
a continued pyrexia with disorder of the stomach has prevailed, 
indicated by whiteness of the tongue, distension, epigastric un- 
easiness, and anorexia ; in some, the bowels become painful, with 
a tendency to diarrhoea, the evacuations being mixed with blood 
and mucus: in others there are wandering pains of the head, 
chest, and abdomen, or lumbar pains, strangury, and bloody 
urine, flushing and oedema of the face, languor, dejection, and 
general indifference ; sometimes the pulse, is quick, at other times 
slow, intermitting, or irregular. In addition to several of these 
symptoms, the patient is occasionally attacked during the inter- 
mission with rigors, slight exacerbations of fever of a hectic kind, 
followed towards evening by a cold clammy moisture upon the 
arms and breast, excessive thirst, sometimes palpitations of the 
heart, cough, and difficult respirations. Whenever these pheno- 
mena are present, and a paroxysm is about to supervene, they 
disappear in the greater conflict the constitution is about to be 
engaged in : but when the paroxysm has passed over, several of 
these anomalies reappear ; so that the patient even in the interval 
may never be left perfectly free from very obvious ailments. It 
is unnecessary to enter more fully into the irregularities which 
occasionally take place during the intermission. From what has 
been stated it is apparent, that though during this period or inter- 
val the patient may remain free from any uneasy sensation, there 
may be more or less evidence of undefined indisposition. 

The alternations of the period of intermission, with the febrile 
paroxysm described, have given the name whereby this class of 



378 INTERMITTENT FEVER. 

diseases is distinguished. Experience has taught us that this al- 
ternation occurs with a regularity so marked, that we are enabled 
to infer the time at which the paroxysm will recur. This periodi- 
city generally discovers itself between the close of the first and the 
commencement of the second paroxysm. Hence is determined 
the type or form of intermittent fever, to which the particular case 
belongs, and which it maintains, speaking in general terms, dur- 
ing the whole course of the disease, not only as regards regularity 
in the recurrence of the paroxysm, but likewise as to the length 
and severity of the different stages of the paroxysm itself, it being 
almost uniformly found that the hot stage is determined in its cha- 
racter by that of the cold, and the sweating by the character of 
the other two together. These exacerbations of fever and inter- 
missions are so well defined and so constant in their succession, 
as to permit the varieties of the disease to be designated by terms 
sufficiently expressive of the period of recurrence. Nevertheless, 
irregularities sufficiently striking occasionally present themselves: 
sometimes the paroxysm is protracted beyond its proper period ; 
sometimes the regular time for its return is anticipated, or it may 
be delayed. The phenomena of the disease, however, bear so 
general a relation to each other, that the following may be almost 
regarded as its proper or peculiar laws : — 1. The shorter the in- 
termission the longer the paroxysm; 2. The longer the paroxysm, 
the earlier it commences in the day; 3. The more durable the cold 
stage, the less durable the other stages. 

We shall now proceed to describe the varieties of intermittent 
fever: — 1. The quotidian; 2. The tertian; 3. The quartan; 4. 
The irregular; 5. The complicated. 

1. The quotidian intermittent is characterized by its intermis- 
sion occurring every twenty-four hours. In this type of ague the 
intermission is shorter than in any other, while the paroxysms are 
the most protracted, occasionally extending to eighteen hours. 
The paroxysms- commence generally in the morning : in fact it is 
doubtful if the disease can ever be considered a true quotidian, if 
they commence after noon or during night. They are usually in 
these cases symptomatic of some local affection. The quotidian 
but rarely occurs, in fact more rarely than is generally supposed ; 
for hasty observation has frequently led to the confounding with 
this type the more commonly occurring double tertian. In this 
latter, however, the paroxysms are not equally severe, the alter- 
nate ones bearing a relation to each other, while in the quotidian 
they each are of similar character. 

The paroxysm of quotidian is ushered in by a slight sensation 
of cold, or rather a chilliness only ; it is usually attended by much 
gastric derangement, as heartburn, nausea, with distension of the 



VARIETIES. 379 

epigastric and hypochondriac regions ; the pulse is irregular and 
weak, the urine pale and thin. In some cases other symptoms 
supervene, as headache, diarrhoea, or vomiting. This stage com- 
monly lasts about three hours. The hot stage is characterized by 
thirst and a general warmth, rather than an intense heat ; the 
patient is frequently drowsy ; the pulse becomes quicker, but does 
not acquire hardness ; the urine is turbid. This condition lasts 
perhaps for two hours or more, when a protracted but slight per- 
spiration announces the sweating stage. The whole of the parox- 
ysm occupies about ten or twelve hours. The intermission which 
succeeds is not entirely free from morbid feeling, the patient usually 
experiencing some degree of heaviness and mental oppression : it 
lasts usually for twelve or fourteen hours, but in severe cases it 
may not exceed six. 

The continuance of quotidian ague is much influenced by cir- 
cumstances, as the age and constitution of the patient, the season 
of the year — the autumnal and winter attack being always more 
severe than that occurring in the spring. It is often protracted in 
its course, especially when it occurs in those of lax weak fibre ; 
its usual progress to a cure being in such cases the transition into 
a tertian. This type of the disease often assumes many peculiari- 
ties : occasionally the paroxysms are so extended, that there is 
scarcely any intermission, or at all events it is very imperfect ; so 
that the whole period between the- paroxysms is not free from 
febrile symptoms : this has been termed the continued quotidian. 
Dr. Fordyce has particularly described another variation under 
the name of the anticipating quotidian, in which the paroxysm, 
instead of recurring at its usual time, sets in about two hours 
before ; and this happens in every attack, so that its recurrence 
may take place at any period of the twenty-four hours instead of 
at the regular time. 

The retarding quotidian is the counterpart of the anticipating, 
its paroxysms being daily postponed for two hours. 

2. In the tertian ague the paroxysm commences every forty- 
eight hours ; it is the most frequent of all the types of intermittent 
fever. The paroxysms usually commence about noon, and rarely 
last so long as eight hours; six are understood to be the fair 
average time. Their duration is consequently less than in the 
quartan ague, and in this respect there is a deviation from the 
general law. 

The premonitory signs of the cold stage are, overwhelming 
languor, continued yawning and stretching of the limbs, creeping 
sensation over the surface, followed by a feeling of coldness down 
the back ; occasionally, though very rarely, this feeling of coldness 
commences in one of the extremities, or on one side of the head. 



380 



INTERMITTENT FEVER. 



To these symptoms succeed the rigor, which is peculiarly intense 
in the tertian variety. It is attended by severe general and lum- 
bar pains, and by anxiety and alarm ; a feeling of nausea super- 
venes, and as this increases the pain subsides : vomiting, first of 
the contents of the stomach and afterwards of bile, succeeds, 
which is the termination of the cold stage. Though this stage 
sets in severely it is not of long duration, rarely exceeding an 
hour, and not unfrequently lasting less than half that time. The 
succeeding or hot stage, as regards the individual paroxysm, is, 
however, disproportionately long; it is not characterized by any 
symptoms very different from the usual hot stage in other agues ; 
the heat is intense, and the thirst continued. It may continue for 
three hours, when it gradually subsides under the influence of a 
free perspiration. The period of apyrexia in this form of inter- 
mittent is often attended by much general derangement, as weak- 
ness, loss of appetite, headache, &c. 

Of all the varieties of ague the tertian when uncomplicated by 
any other disease, is the least dangerous, especially when it 
occurs in the spring; those that occur in the autumn are more 
obstinate, and change, at times, into the quotidian, or the double 
tertian. In favourable cases it may subside after the fourth pa- 
roxysm ; it often does so after the fifth, but more generally after 
the seventh or ninth ; occasionally the disease subsides on the 
appearance of a scabby or vesicular eruption ; the occurrence of 
any little cutaneous disease about the nose and mouth may 
be almost considered as critical. This type of intermittent oc- 
curs more frequently in adults than in children, and in those of 
robust sanguineous temperament than in the leucophlegmatic. 
It is often complicated with chronic diseases, especially of the 
stomach and liver, and with dysentery. 

The irregularities which occur in tertian ague are very nume- 
rous, and of frequent occurrence ; they may, in great measure, 
however, be included under the heads of double and triple tertians. 

In the double tertian the recurrence of the paroxysm takes 
place daily, so that two fits and two intermissions occur in the forty- 
eight hours; and on which account, as previously noticed, it may 
on slight observation be confounded with quotidian. It differs 
somewhat from this latter in the paroxysm not occurring in the 
morning, but more particularly in the alternate ones being similar, 
while those immediately following each other are not so; thus 
the paroxysm of the first day comes on at noon, and goes through 
its stages as is usual in a tertian ; on the following day, the period 
of apyrexia is obtruded upon towards evening by a slighter 
paroxysm ; on the third day the phenomena are the same as 
occurred on the first day, and on the fourth as on the second; so 
that the paroxysms occurring on the first, third, and fifth days, 



VARIETIES. 381 

represent those that belong properly to the type of ague, while 
those occurring on the second, fourth, and sixth days are those 
which constitute the variety, and are the irregular addition to the 
disease. Dr. Davis, who says this is the most common type of 
the fever, describes it as attacking at all hours, generally begin- 
ning with nausea, extreme lassitude, and sense of cold, extending 
from the shoulders to the bottom of the back ; that in the cold 
stage, independent of the usual symptoms, the dejection of spirits 
increases so much " as in many instances to approach syncope, 
resembling a fever termed by the ancients Syncopalis" The 
symptoms attending the paroxysms he has detailed at great length 
and with much minuteness ; but as they are not essentially differ- 
ent from those already stated, it would be useless to dwell upon 
them here. 

Some of the irregularities of the double tertian are not, how- 
ever, uninstructing. The cold stage sometimes consists of a rigor 
only, followed, after the space of an hour or two, by great heat, 
continuing for an uncertain number of hours, varying from six 
to eight. In the slight and irregular paroxysm, ushered in fre- 
quently by rigor and moderate febrile symptoms, the termination 
is always more confused and incomplete than the severe parox- 
ysms of the previous or following day. On the termination of 
the fit being tolerably complete, there yet remain symptoms 
which are very distressing, such as acute pain in the chest, sto- 
mach, or head. If the pain in the head continue long, delirium 
or stupid drowsiness follows, and diarrhosa, sometimes dysentery, 
and partial suppression of urine frequently occur. In the midst 
of the hot stage, palpitations of the heart, cough, and vomiting, 
occasionally supervene, together with repeated hemorrhages from 
the nose ; many of which symptoms persist after the completion 
of the paroxysm, thus creating considerable confusion during the 
interval. The duration of the paroxysm is occasionally very 
uncertain, being much influenced by a complication of anoma- 
lous symptoms : — " It has occasionally lasted ten, twelve, fifteen, 
or twenty hours without coming to any distinct solution ; nay, the 
stronger fit has continued till the slighter one has commenced, the 
two paroxysms becoming thus identified in one. The interval 
has in some instances really been so indistinctly marked, that the 
fever partook much of the continued or at least remittent form." 
Much irregularity also occurs in respect to the invasion of the 
paroxysms, now occurring regularly both as to period and dura- 
tion, and then those immediately following varying in both these 
respects. Sometimes a variety is established which has been 
termed the duplicated tertian, in which, according to Cullen, 
two paroxysms occur on alternate days, while the intervening 
ones are days of intermission. Dr. Craigie describes it some- 
what differently, the disease being introduced, according to him, 



382 INTERMITTENT FEVER. 

with a mild fit in the evening, and followed by a more violent 
and complete one the succeeding day. On the evening of the 
third day again a mild fit appears once more, and is succeeded 
by a severe one in the same manner throughout the disease ; so 
that according to the usual mode of calculating the days of dis- 
ease by reckoning from the first hour of invasion, both parox- 
ysms happen on the odd days, while a great part of the even 
days is calm and undisturbed. 

In the triple tertian there are two paroxysms on the odd and 
one on the succeeding days ; so that in forty-eight hours there are 
three paroxysms and three intermissions. The mode of this 
occurrence follows somewhat this order. About midday the first 
paroxysm occurs and lasts for four or five hours ; after a short 
intermission another takes place, which is protracted through the 
night ; then follows an intermission during the greater part of the 
second day, which towards evening is intercepted by a paroxysm 
lasting through the night ; on the third day the two paroxysms 
reappear as on the first, and on the fourth day as on the second, 
and so on throughout the disease. 

3. The quartan ague is characterized by an intermission, com- 
mencing every seventy-two hours, the paroxysm generally lasting 
from five to nine, and commencing usually in the afternoon be- 
tween the hours of two and five. Its cold stage is longer in pro- 
portion than in the other types, but it is by no means so violent 
as in the tertian. Dr. Craigie, however, on the authority of 
Burserius, describes the hands and feet as becoming cold, the 
whole body pale, the face and nails livid, succeeded by shudder- 
ing, and at last by convulsive shivering, trembling of the tongue 
and lips, frequent and oppressive breathing, with a sense of 
anxiety at the prsecordia, and a shaking of the whole person with 
irresistible violence. In some instances this degree of cold and 
shivering does not take place in the first and second paroxysms ; 
but in the subsequent ones it is always very violent, and has been 
known in some cases to break the teeth or dash them from their 
sockets. The cold stage is occasionally protracted to a period of 
two hours, and is very rarely attended by sickness or diarrhoea. 
After a duration of two or three hours it passes into the next 
stage, which is not attended so much by intense as by a trouble- 
some dry heat; nor is the concluding stage marked by any very 
decided perspiration. 

This form occurs chiefly in the autumn, very rarely in the spring. 
The subjects most liable to it are those in advanced years, and of 
a melancholic habit. Of all the types of intermittent it is the 
most obstinate and difficult of cure, generally remaining through 
the winter until the following spring. Celstjs has remarked this 



VARIETIES. 383 

particularly to be the case, should this form of ague become 
established in the constitution before the winter have set in. It 
is nevertheless a type of fever, which is very rarely attended by 
a fatal termination. 

The deviations from the ordinary course of the quartan bear 
so much relation to those of the tertian already described, that it 
is not necessary to enter at length upon them. A few words will 
suffice to show the nature of these variations : — 

In the double quartan the true paroxysm takes place on one 
day, a slighter one on the second, while the third is a day of 
intermission ; on the fourth day another paroxysm takes place, 
resembling that of the first, and so on in succession. The parox- 
ysms occurring on the second and subsequent fourth days are 
those which represent the type of the disease. 

In the triple quartan a paroxysm takes place daily, but they 
vary on the first, second, and third days ; so that, as the disease 
progresses, the paroxysms which occur on the first and fourth, on 
the second and fifth, on the third and sixth, and so on successively, 
are respectively similar. Those occurring on the first and fourth 
days being the most complete, are the true quartan paroxysms. 

In the duplicated quartan on the first day two paroxysms 
occur, while the second and third are days of intermission. In 
the tripled quartan these paroxysms occur on the first and fourth 
days with two days of intermission. These two latter varieties 
are of very frequent occurrence, but in their progress towards 
cure they usually pass into the true quartan. 

The irregular agues are those whose periods of intermission 
are more protracted than in any of the preceding ; and though to 
the hasty observer the recurrence of the paroxysms may appear 
to be irregular, yet, for the most part, they will be found to obey 
certain laws of periodicity. In these varieties the intermission 
which intervenes is protracted through the space of from five 
(called by Van Swieten a Quintan) to seven days, or even to a 
longer period. Dr. Craioie, however, thinks it exceedingly 
doubtful that an ague should actually exist with periods of inter- 
mission so extended, and at the same time observe any so marked 
regularity in the accession of its paroxysms. 

The whole class of simple agues, together with their varieties, 
are subject to certain irregularities in their paroxysms, which have 
given rise to a division into the cold, burning, and sweating 
agues — the accompanied agues of many writers. They occur, 
however, most frequently, as deviations from the autumnal ter- 
tian. 

In the cold variety the first stage is protracted, the surface re- 
maining chilly, the pulse depressed, the countenance sunken, and 



384 INTERMITTENT FEVER. 

the breathing anxious ; no hot stage is perceptible ; it gradually 
subsides into a clammy perspiration. 

The hot variety is, in its external symptoms, very similar to 
the cold, excepting that, whilst the surface retains its coldness, 
there is felt within an excessive and most excruciating burning. 

In the sweating variety the cold and hot stages are hurried 
through, and a protracted sweating stage supervenes. The per- 
spiration is very copious, exhausting, and enfeebling. Each of 
these varieties is attended by much danger. We shall not, how- 
ever, enter further into their discussion, as the irregularities in the 
paroxysm have been already pointed out. 

4. In the complicated agues, one type may be converted into 
another — the tertian and quartan into quotidian, or into double or 
triple tertians; quotidians and tertians into remittents, &c. A 
variety of the complicated has been termed the subintrant, in 
which the paroxysms approach each other so nearly as to be like 
remittents, excepting that the exacerbations are more marked. 

The above may be stated to be the more usual forms in which 
intermittent fever occurs. Each type, however, is liable to cer- 
tain modifications, which have their origin in idiosyncrasy, or the 
presence of some general affection, or on what has been termed 
atmospheric temperament. These modifications, from altering 
very considerably the general character of this class of fever, 
render a true appreciation of them very necessary in a practical 
point of view. 

The most important of these modifications are, 1. The inflam- 
matory; 2. The congestive ; 3. The malignant. 

1. The inflammatory intermittent is characterized by its inter- 
missions not being free from febrile symptoms, notwithstanding 
the sweating stage of the paroxysm has been most complete; the 
pulse retains much of its quickness and tension ; the thirst is con- 
stant and urgent, the skin harsh, dry, and warmer than natural ; 
the whole tone of the system is irritable ; the temper is fretful 
and discontented ; there is headache, and occasionally aching 
pains transiently affecting the extremities, and sometimes slight 
pain of the chest, attended by a short cough. In agues thus 
modified the rigors are exceedingly strong, and generally attended 
by vomiting. The paroxysms are usually protracted, and the 
intermissions are proportionally shortened. The quotidians are 
more apt to partake of this character than the tertians, and the 
tertians than the quartans. The vernal quotidians, occurring in 
the young and robust, are particularly liable to become so. 
Richter has observed that, notwithstanding the general severity 
of the symptoms, the secretions are rarely so vitiated as to cause 
gastric disturbance. 



VARIETIES. 385 

2. The congestive form of ague is throughout of adynamic cha- 
racter. The cold stage, which is much protracted, is ushered in 
by vertigo, deep-seated- pain of the head, followed by general trem- 
bling rather than rigor. The pulse is small and weak, and not 
unfrequently faintings and coma add to the alarm. The hot stage 
struggles on slowly, and, as it were, unwillingly, and then is but 
imperfectly developed ; so that, instead of the usual characters of 
this stage, there is only a low oppressed condition. The sweating 
stage is scarcely perceptible. The period of intermission is marked 
by a pale, worn, contracted countenance, general oppression of the 
system, constricted and anxious breathing, and small, hard, and 
frequent pulse. The surface of the body is colder than usual, with 
an incapacity of retaining the surface warmth at the same time 
that the internal parts feel heated and irritable. This modification 
of ague, however, seldom occurs, excepting in hot countries, where 
there is much prevailing marsh exhalation, and then only in those 
constitutionally nervous and irritable, or whose health has been 
impaired, and the powers of the system exhausted by previous 
disease. Boisseau states, that it occurs in quotidians, double ter- 
tians, tertians, and quartans; it sometimes takes on alternately these 
different types, whilst at other times they are irregular. (Pyr'etolo- 
gie Physiologique.) The duration of the congestive intermittent 
is but little known: it occasionally succeeds the adynamic con- 
tinued fever ; though, more frequently, it passes into the continued 
form. It is a peculiarly fatal variety of ague. 

3. The malignant form of intermittent fever has been particu- 
larly described by Alibert. (Traite des Fievres Pernieieitses In- 
termit tent es.) After the second, third, or fourth accession of the 
febrile paroxysms, the cold stage becomes either shorter and more 
intense, or else very much prolonged ; and in place of the pheno- 
mena usually attendant on the hot stage, urgent symptoms, hitherto 
not observed, show themselves ; or those which had already cha- 
racterized this stage are much exasperated. The sympathetic 
phenomena which specially characterize the febrile accession be- 
come less apparent, or cease almost entirely, while symptoms of 
local irritation, hitherto unperceived, become developed. Never- 
theless, the paroxysm passes off without any very well-pronounced 
perspiration, but a fetid odour is often exhaled from the body. The 
patient in part recovers his powers and appetite, and sometimes 
even does not complain of any particular uneasiness. On the 
accession of the succeeding paroxysm, however, colliquative he- 
morrhages and petechias often make their appearance ; and not 
unfrequently death ensues at this period, or the disease may be 
protracted to the third, fourth, or fifth paroxysm. 

Such is the outline of what French writers have termed Filvres 
intermittentes pernieieitses : they usually occur in warm climates 
25 



386 INTERMITTENT FEVER. 

in persons of broken-down constitution, as well as when the inter- 
mittent fever is complicated with organic diseases. 

[The subject of the pernicious forms of intermittent fever is one 
of great interest to the practitioners of an extensive district of this 
country, where these varieties prevail to a greater or less extent. 
Those forms to which the term pernicious is applied, are, in reality, 
cases characterized by the greater violence of the accompanying 
congestions, and where, from the importance of the organs impli- 
cated, death is imminent at the third or fourth accession. 

A highly interesting account of an epidemic ague, of the per- 
nicious variety, occurring in Persia in 1842, has been given by 
Dr. Charles W. Bell, Physician to the British Mission.* It was 
essentially a quotidian ague, characterized by intense general con- 
gestion of the venous system. The disease had several modes of 
commencement. " Sometimes it began at once, by the patient 
becoming suddenly insensible without previous symptoms ; at other 
times it was preceded by formal ague. In many instances, again, 
the patient would suffer for some time previously from intermitting 
headache daily increasing, and great want of sleep ; he would then 
have one attack of ague, and, next day, at the same time, would 
sink down insensible. This was the form of disease from which 
the greatest number of deaths took place, and obtained for the 
malady its Persian name tab-i-ghash, or 'fainting fever/ During 
the insensibility the pulse was feeble and the extremities cold. 
From this state many were never roused; but if they were, the 
pulse gradually attained power, and the patient came slowly to his 
senses, complaining of intense headache and a feeling of oppres- 
sion at the heart; a low kind of fever then came on which was 
succeeded by very imperfect perspiration, generally confined to the 
head and chest. Next day, about the same hour, insensibility re- 
turned, and each attack continuing longer than the preceding one, 
the period of death depended upon the strength of the patient or 
violence of the disease; most frequently, however, death took 
place on the third attack. As the end approached the secretion of 
urine ceased, the efforts of the heart at reaction became feebler, 
the skin felt like that of a corpse, cold and damp, the body became 
purple and mottled, and the pulse became less perceptible at the 
wrist: at length the patient was seized with tetanic convulsions 
and died. In these cases, as often observed in cholera, the feet 
began to get warm shortly before death, and just as the warmth 
had spread up the legs and reached the trunk the patient died. 
Indeed, were other symptoms wanting, I should consider warmth 
commencing in the feet while the rest of the body was cold, quite 
sufficient to mark the case as hopeless." In another form, resem- 
bling the algid of southern countries, there was " no insensibility, 

* [Report on the Epidemic Ague, or "Fainting Fever," of Persia, &c. British 
and Foreign Medical Review, vol. xvi., p. 558. London, 1843.] 



VARIETIES. 387 

no shivering, little or no perceptible fever, and no perspiration ; the 
primary characteristic symptoms were a fixed pain in the pit of the 
stomach, extreme tenderness on pressure over the left lobe of the 
liver and region of the spleen, and extreme tension of the abdomi- 
nal muscles. One or both of the recti abdominis became hard as 
a board, continuing for days in a state of constant tension, but 
"without any painful cramps or spasms. Nearly at the same hour 
each day the patient was observed to become exceedingly anxious 
and restless, tossing from side to side, sighing and throwing the 
arms above the head, as in yawning, and the pulse became very 
small and frequent, and the body damp and cold. By and by, this 
oppression passed off, the body resumed its natural warmth, and 
the pulse nearly its natural volume ; but this continued quicker 
than usual, and then to all appearance the patient had very little 
the matter with him. Each day, however, the oppression of the 
circulation became greater and the attack continued longer; the 
pulse now became weaker, and an ice-cold exudation ran off the 
brow and back of the hands. The struggling of the heart to over- 
come the load of blood which oppressed it was most painful to 
listen to, — now almost overcoming the obstruction, the pulse for 
an instant gaining power, and a partial warmth spreading over the 
surface ; and, again, the force of the heart succumbing to the dis- 
ease, and the icy coldness — much colder than death — returning. 
The craving for iced water was incessant so long as this state 
lasted. The evacuations meantime were bilious, and the quantity 
of urine daily diminished, and at length ceased altogether. At 
length the intermission between the attacks of oppression ceased 
to occur, the pulse was only perceptible at intervals, and the 
patient, who up to this time had been perfectly sensible and even 
able to walk to stool, fell into a state of stupor. The skin now 
became blue and mottled, and the patient gradually sunk or died 
in convulsions. Here, also, as I remarked above, some time before 
death took place, the lower limbs recovered almost their natural 
warmth. In all the cases I saw of this variety there was much 
feeling of distension of the stomach and inactivity of the bowels, 
and sometimes a little vomiting." The great and rapid enlarge- 
ment of the spleen is particularly mentioned. In many instances 
pain in the region of the spleen was felt before the occurrence of 
any other symptom. The blood was of a dark, dusky, reddish- 
brown colour, and in general the serum did not separate from the 
clot. In those affected with the severer forms of the disease, the 
blood drawn in the cold fit was always grumous, coming at first 
slowly or in drops, and coagulating as soon as drawn, even at the 
mouth of the wound ; and no separation of the serum took place. 
During the epidemic the urine of the people in general was much, 
darker coloured than at other times, while in those who were seri- 
ously affected it was, if secreted at all, like porter, and in very small 
quantity.] 



388 INTERMITTENT FEVER. 



III. COMPLICATION WITH LOCAL AFFECTIONS. 

Complicated intermittents, both from the nature of the lesions 
and from their frequency, are of the highest importance ; we shall 
therefore describe the most prominent local affections. 

It is not always easy to determine whether these local lesions 
are primary or secondary, or to what extent they constitute the 
danger. It is also to be kept in mind, that some peculiar state of 
the atmosphere, or the peculiar nature of local miasm, or both, 
exert, a powerful influence on the general character of the fever, 
while individual cases are greatly modified by peculiar idiosyn- 
crasy : thus, in those of plethoric habit, the brain is much affected, 
and in such persons there is a tendency to delirium ; in those of a 
nervous or irritable disposition, in addition to the other symptoms, 
there are spasms and twitchings of the tendons ; and individuals 
who are predisposed to rheumatism suffer much from acute ar- 
thritic pains. [Good.) 

The most frequent complication, and one attended with much 
danger, is that which is termed the gastric, in which there is in- 
flammation of the mucous membrane of the stomach. The symp- 
toms are, excruciating pain in the epigastrium towards the cardiac 
origin of the stomach, from which Boisseau has called it, La 
Jievre pernicieuse cardialgique : the pain is of a gnawing or tear- 
ing character, attended by nausea and sometimes vomiting ; the 
countenance is pale and altered; the pulse is quick and small, or 
even scarcely perceptible ; the skin hot ; the tongue dry, brownish 
yellow or bright red; the urine scanty, high-coloured, and of a 
yellow tinge ; the thirst urgent ; to which succeed hiccough, great 
prostration of strength, impaired vision, and hurried breathing. 
These symptoms supervene after a short shivering fit at the com- 
mencement of the hot stage. When the liver partakes in the mor- 
bid action, the febrile paroxysm is preceded by frequent copious 
evacuations, intermixed with portions resembling broken-down 
flesh, or dark blood partly coagulated and partly liquid : the fluid 
which is vomited being of the same description. 

The prostration of strength in such cases is extreme ; the pulse 
feeble and small ; the voice shrill ; and the general surface of the 
body, but more especially the extremities, cold. On any attempt 
to rise from the horizontal position, syncope often takes place, an 
event which is always much to be dreaded, as the powers of reac- 
tion are very feeble. According to Boisseau, all the symptoms of 
the atrabilious or hepatic intermittent indicate violent irritation of 
the intestines, in which there is more or less intense sanguineous 
engorgement. 

When intermittent fever is complicated with cerebral disease, it 
takes on various forms, the symptoms of urgency being generally, 
however, referable to the head ; acute lancinating pains are felt, 



COMPLICATIONS. 389 

more particularly over the frontal region and in the orbits ; the 
sight is impaired ; there is great sensibility to light, the retina ap- 
pearing to be in a state of the most excessive irritability ; there is, 
at the same time, painful tinnitus aurium, with intolerance of 
sound ; in short, the group of symptoms indicate that the mem- 
branes of the brain are inflamed. When coma is superinduced, it 
generally sets in with a drowsiness towards the end of the cold 
and beginning of the hot stage ; the pulse is slow, at one time full, 
at another small ; the eyes are fixed, the lids half open and im- 
movable ; the expression of the countenance death-like ; and the 
patient mutters, replies with difficulty, appears inattentive, asks 
questions, and then forgets them. During all this time he appears 
perfectly sensible of the inaccuracy of his mental powers, and 
appears labouring to collect his ideas. If the coma become com- 
plete, the breathing is stertorous. In this state the patient usually 
remains for the space of one or two hours, and then continues free 
until the following paroxysm. At other times the paroxysm is 
accompanied by delirium. This state is attended by thirst, hot 
skin, feeble pulse, great efforts being generally made at muscular 
exertion, with constant desire to leave the bed. 

Cerebral intermittents have also been attended by convulsions ; by 
epileptic fits (Lautter)-, by spasm of the glottis, resembling in many 
respects the paroxysm of hydrophobia (Damas)\ by loss of voice 
(Double)-, and by paralysis (Molitor and Sonquet); in fact, when 
cerebral inflammation takes place as a complication of intermittent 
fever, all those consequences which are usual on the simple inflam- 
mations of the brain and its membranes, are developed during the 
paroxysm. Dr. Brown (Cyc. of Pract. Med.) states, that the symp- 
toms which are distinctly referable to the brain and its membranes, 
are of two orders — those of spasm or convulsion, and those of coma 
or oppression. Amongst those of the former, he says, there is not 
merely the ordinary subsultus of fever, but well-marked convulsive 
movements, such as the rapid contraction of the flexor and extensor 
muscles of the forearm, convulsive twitchings of the fingers, occa- 
sionally tonic spasms of the same parts or of the lower extremities, 
so that the flexors and extensors being balanced, the members ac- 
quire a tetanic rigidity, firm clenching of the lower jaw, and violent 
rolling or distortion of the eyes. The signs of diminished sensibility 
are stupor,from which it is difficult or impossible to rouse the patient; 
immobility; incapability of swallowing ; eyelids wide open; pupils 
occasionally dilated, sometimes morbidly contracted ; pulse some- 
times strong and bounding, at others small and feeble ; and stertorous 
breathing. Should both sets of symptoms occur in the same patient, 
it will generally be found that those of convulsion precede in point 
of time, though in the close of the disease they are found co-exist- 
ing. Dr. Brown quotes M. Lallemand as considering the first 
set of symptoms— those of convulsion — to arise from inflammation 
of the arachnoid membrane, communicating irritation to a healthy 



390 



INTERMITTENT FEVER. 



brain, or at least to one retaining its functions to a certain extent; 
while the second — those of coma — are due to inflammation of the 
cerebral substance itself. It is certain that convulsive movements 
are compatible, and are indeed generally found co-existing with 
coma, more or less considerable ; but the opinion of M. Lallemand 
is supported by the facts, that in those cases of comatose intermit- 
tent, in which there are convulsive movements, the patient is still 
capable of being roused to a degree of attention, and to display 
some share of sensibility ; and that in cases of coma without con- 
vulsion, the marks of cerebral inflammation are more considerable 
than in those in which convulsions existed. The cerebral symp- 
toms usually come on suddenly, though rarely until after a series of 
paroxysms have taken place. They require the most prompt and 
judicious attention ; for not only are they frequently followed by a 
state of complete and permanent idiocy, but occasionally death itself 
ensues suddenly during a paroxysm. Sydenham, however, who 
had observed that after a reduplication of the fits and repeated eva- 
cuations patients were often seized with madness, states, that as 
their strength increased and they otherwise began to recover, this 
state proportionably subsided : but in another place he adds, " it 
may however be proper to take notice of a considerable symptom, 
which neither yields to purging, nor any other evacuation, and 
especially not to bleeding, but is rendered more violent thereby. 
This is a peculiar kind of madness, which sometimes follows upon 
inveterate intermittents, especially quartans, and yields not to the 
ordinary method of cure, but after copious evacuations, degene- 
rates into a lamentable kind of folly for life." ( Works by Swan.) 
Mosely states that Dr. Charles Irvine informed him, that when 
on the Spanish Main, the delirium which commonly came on in the 
paroxysm of the fever, after a few returns of it, sometimes re- 
mained during the intermissions, which soon became irregular from 
reduplications of the accessions ; and that several men wandered 
about in a frenzy, and died raving mad. Mosely himself says, 
that he has frequently observed that the mind has been greatly 
impaired after irregular and harassing intermittents; and sometimes 
that a temporary insanity ensued. ( Tropical Diseases.) 

[In the comatose form, according to Maillot,* the stupor may 
vary in degree from simple oppression to profound cams. The 
pulse is full, large, without hardness, sometimes quickened, occa- 
sionally retarded; the respiration is slow, noisy, and stertorous. 
The patient lies supine, and his limbs seem paralyzed; the jaws 
are firmly locked, and deglutition very difficult ; sometimes there 
are epileptic spasms. These severe symptoms commonly occur 
unexpectedly in the second paroxysm, no apprehension of their 
occurrence having been excited by previous symptoms, except it 

* [Traite des Fievres, ou Irritations Cerebro-Spinales Intermittentes, &c, Par 
F. C. Maillot, D. M. A. Paris, 1836.] 



COMPLICATIONS. 391 

be some slowness of speech in the apyrexia. After the contin- 
uance of the comatose stage for an uncertain and variable length 
of time, the sweating stage supervenes, and the patient slowly re- 
covers, wearing an extraordinary air of astonishment, and seeming 
to regain his senses one by one. In the delirious form, the same 
authority states, that death may take place suddenly, without the 
supervention of coma — " life being broken by a sudden shock/'] 

When intermittent fever is complicated with disease of the pul- 
monary organs, there is generally, during the paroxysm, intense 
pain of the chest aggravated on inspiration, dyspnoea, cough, thirst, 
dry tongue, small and quick, afterwards hard and frequent, pulse, 
general feebleness, and universal chilliness. Cases of this descrip- 
tion usually set in with a violent rigor. If there be a sharp pain on 
either side, it may generally be inferred that the pleura is affected. 
The state of a patient under such circumstances is imminently ha- 
zardous. Dr. Davis states, he never found intermittents so dan- 
gerous as when the original fever was combined with pneumonia 
or hydrothorax. Laennec relates a very interesting case of this 
nature which is important as establishing the fact, that the physical 
condition of peripneumony was present during the accession, and 
subsided afterwards. Towards the middle of the paroxysm the 
rale crepitant was heard, and there was a slight haemoptoe. Dr. 
Stokes has likewise detailed a case in many respects similar to this. 
(Edin. Med. and Surg. Journ., vol. xxxi.) 

When complicated only by simple catarrhal affection, the symp- 
toms are not essentially different from the above. The only points 
of distinction are, that the cough is not dry, the eyes are more suf- 
fused, and the face is red and swollen. Should the cough, however, 
be severe, headache supervenes, and sometimes convulsion, followed 
by a state of drowsiness. 

If complicated with asthmatic symptoms, though there be no 
pain, yet the respiration is so difficult as to threaten suffocation. 
This symptom is most alarming. In these cases, although there is 
much short and distressing cough, there is no expectoration. 

When complicated with disease of the heart, there is palpitation 
with pain in this region. These symptoms occasionally exist to so 
great an extent as to induce those indefinable sensations which pre- 
cede syncope. All the senses but that of hearing are abolished, and 
the patient attempts to speak, but cannot. During this state the 
arterial pulse and respiration appear to have entirely ceased, and 
the beatings of the heart are very feeble and slow. This state 
usually lasts for a quarter of an hour ; at times it is protracted to 
an hour or even two. 

In that variety which is termed the syncopal, the patient loses 
knowledge of all impressions for a short time ; and, on recovering, 
complains of no pain nor other inconvenience, excepting that re- 
resulting from extreme languor and feebleness. The symptoms 



392 INTERMITTENT FEVER. 

attending a paroxysm of the fainting ague are small, depressed, and 
frequent pulse, hollowness and dullness of the eye, the head and 
neck being covered with a most profuse perspiration. It generally 
proves fatal after five or six attacks. 

Disease of the spleen is very frequent in intermittent fever, so 
much so that certain alterations in its structure have acquired the 
name of ague cake. Dr. Davis thinks that the diagnosis may be 
deduced from the " leaden green and bloated appearance of the 
face, the debility and listlessness of the whole body, as well as 
from the accessions of fever which are truly hectic." 

[Enlargement of the spleen, though not a constant, is an ordi- 
nary accompaniment of intermittent fever of any duration. In 
161 cases of intermittent fever, Dr. Piorry, found the spleen to 
exceed the normal size in 154. It is said to occur much more fre- 
quently after tertians and quartans than quotidians. When incon- 
siderable, any increase in size can only be ascertained by percus- 
sion ; but when the organ projects beyond the costal margin, it is 
readily detected by palpation. It sometimes extends as low as 
the umbilicus, and may reach to the crest of the ileon. Dr. Pi- 
orry, who has paid great attention to the condition of the spleen 
in ague, asserts that in about one-half of the cases, pain, or a feel- 
ing of heaviness, is complained of in the left hypochondriac region. 
At other times these sensations are only elicited by palpation or 
on percussion.] 

This list of the complications of intermittent fever with local dis- 
ease might be greatly extended : we might detail the icteric, the 
cystic, the uterine, the algid, the petechial, &c; in fact, authors 
might be quoted who have described its occurrence under a vast 
variety of anomalous circumstances, and in conjunction with the 
symptoms and lesions of almost every local and general disorder. 
To enter upon these, however, would be very tedious, and rather 
curious than useful. We may, however, incidentally remark, that 
the peculiar affection of the nerves termed tic douloureux, often 
takes on a very marked periodicity ; and that its occurrence under 
such circumstance in the branches of the supraorbitar nerve, has 
acquired the term of brow ague. 

[The algid form (with prolonged and icy coldness), of pernicious 
intermittents is very peculiar. Dr. Maillot contends* that it is 
not an indefinite prolongation of the cold stage. He says in the 
first stage of an intermittent, the sense of cold experienced by the 
patient is out of all proportion to the actual reduction of tempera- 
ture ; whereas, in the algid fever, although the skin is icy -cold, the 
patient does not complain of coldness. And this cold state super- 
venes after reaction has commenced, and often suddenly. The 
circulation becomes disturbed, lowered, and the pulse can scarcely 

* [Maillot, loc. cit.] 



DIAGNOSIS. 396 

be felt, the temperature of the body at the same time rapidly de- 
creasing. The extremities, the face, the trunk, become cold in suc- 
cession, the abdomen remaining longer warm. The skin has the 
coldness of marble. The tongue becomes pale, moist, and cold, 
the lips are without colour, and the breath is cold. There is no 
thirst, and attempts to drink often excite vomiting. The actions 
of the heart become feeble, and only appreciable by auscultation. 
The intellectual faculties are undisturbed, and there is a sense of 
repose which is agreeable to the patient. All facial expression is 
lost. With this state, cholera may become conjoined, and. the eyes 
then become hollow, glassy, and surrounded by a bluish circle. 
The approach of the algid form is so insidious as often to be mis- 
taken for a remission produced by blood-letting, and the practitioner 
is only undeceived by the suddenness of the death of the patient. 
This deceitful calm is very strongly pointed out by M. Bailly, in 
his chapter on Diagnosis : he says that the patient may be walking 
about a few instants before his last attack : the accession is sudden ; 
he lies down, and dies in few hours. Even when the pain (of the 
abdomen) and the danger are both considerable, the face has an 
appearance of calmness, as if its expression was no longer asso- 
ciated with the sufferings of other parts. Whenever, says Dr. Mail- 
lot, a sudden retardation of the pulse succeeds to reaction, and 
there is paleness of the tongue and discoloration of the lips, we 
should not hesitate to pronounce the case algid. Temporizing 
measures will be followed by death in a few hours. The patient 
dies as by an arrest of the innervation. If death does not take 
place, the pulse rises, the skin reacquires its natural warmth, and 
sometimes irritation of the brain or intestinal canal succeeds. Even 
this dangerous affection sometimes yields to remedial measures. 
The resemblance between this condition and cholera is commented 
upon by Dr. Maillot.] 



IV. DIAGNOSIS. 

The diagnosis in intermittent fever is by no means difficult ; the 
only affections with which it may be confounded are remittent and 
hectic fevers ; the former, however, never has a complete apy- 
rexia, nor are the cold and sweating stages very perfectly pro- 
nounced. In hectic fever the accession takes place daily, and in 
the afternoon or towards night, thus differing from the quotidians 
and double tertian, the only forms of ague likely to be mistaken 
for it. Besides, in hectic fever, the sweating stage is more pro- 
longed, and the pulse, during the intermission, retains more of its 
febrile character, continuing small and rapid. 



394 



INTERMITTENT FEVER. 



V. PROGNOSIS. 



The prognosis in intermittent fever depends on a variety of cir- 
cumstances. The probable result is in some degree influenced by 
the type of the fever itself, by its epidemic character, by the age 
and constitution of the patient, and by the situation in which he 
resides. 

In general terms we may state, that in England intermittent fever, 
when uncomplicated with local disease, is to be considered amongst 
the least dangerous of the class to which it belongs : it must be borne 
in mind, however, that occasionally the simple intermittent proves 
fatal, and then generally in the cold stage. The history of such an 
event usually is, that cerebral congestion ensues, which terminates 
in coma or apoplexy. This is especially the case where a predispo- 
sition to cerebral fullness has previously existed. In those countries, 
however, where, to the baneful influence of excessive temperature, 
are added the effects of marshy swamps, these fevers prove emi- 
nently fatal, ever showing a tendency to pass into the malignant or 
remittent forms. 

When intermittent fever occurs in those who are young and of 
vigorous constitutions, it is much less dangerous than in those who 
are weak and debilitated, or whose habits have been dissipated. 
Death amongst these latter frequently ensues during the cold stage, 
from their stamina not being equal to effect that degree of reaction 
which is necessary to rouse the system from its depressing influence; 
and they succumb to the coma which is thus induced. The form 
and pathological condition of the fever itself likewise influence the 
result : tertians are the most easy of cure, quartans the most obsti- 
nate, but the least fatal, while quotidians are the most fatal. As in 
other acute diseases, we find epidemic influences giving to ague at 
one time a character of fatality which does not belong to it at an- 
other. 

Its complications with other diseases, and its assuming of itself 
the malignant form, are circumstances which must be well weighed 
before pronouncing an opinion as to the probable result. Suppos- 
ing, however, all things to be equal, it may be stated in general 
terms, that the favourable signs are, regularity during the progress 
and in the recurrence of the paroxysms, or in their being retarded ; 
complete reaction after the cold stage during the intermission ; the 
digestive organs performing their function properly, especially if 
there be present no signs of inflammation in the stomach or intesti- 
nal canal ; the return of discharges which had been suspended ; the 
appearance of scabby and humid eruptions about the nose and 
mouth, &c. 

The circumstances which indicate an unfavourable prognosis 
are, irregularity in the recurrence of the paroxysms, especially if 
they become anticipated, or show a tendency to assume the remit- 



PROGNOSIS. 395 

tent and continued forms, which changes are particularly favoured 
by whatever is capable of causing or augmenting the general 
inflammatory condition of the system, or by the supervention of 
some local inflammation. These complications have been shown 
to be particularly severe in their nature, and are generally fatal. 
An unfavourable character of disease during the paroxysm is indi- 
cated by general weakness, difficult and oppressed respiration, hic- 
cough, sighing, coma, and delirium ; and, during the intermission, 
by debility of the stomach, deranged digestion, tumid and hard 
abdomen, loss of strength, tendency to dropsical effusions, difficulty 
of generating or retaining warmth, dyspnoea, bloody urine, &c. 

The terminations of intermittent fever are very various, depend- 
ing much upon the constitution of the patient, the duration of the 
disease, and the virulence or intensity of the exciting cause. The 
conviction of those who have had ample opportunities of witness- 
ing the occurrence of these diseases is, that there exists a natural 
tendency in them to terminate favourably of themselves. Dr. 
Eberle states, his own observations have led him to conclude 
that, if not controlled, or embarrassed by external influences, quo- 
tidians when simple and regular show a disposition to complete their 
course on the seventh day ; tertians on the fourteenth ; while quar- 
tans generally run on to the sixth week. It is not to be expected 
that, under such circumstances, they will always terminate sponta- 
neously at these several periods ; but that their tendency to do so 
is so strong that, if assisted by a febrifuge, the disease will most 
probably be arrested. It is a curious fact in the history of inter- 
mittent fever, that occasionally a continued and obstinate autumnal 
ague is superseded by the milder vernal one, which running 'its 
usual course terminates in health, and apparently quite uninflu- 
enced by the previous disease. We have alluded to the frequent 
termination of agues in a scaly or vesicular eruption, which makes 
its appearance about the nose and lips : its occurrence is considered 
critical. 

Should the intermittent, instead of presenting this favourable his- 
tory, be protracted, a state of impaired health becomes established. 
The condition of those who are thus labouring under its sequelae is 
sufficiently marked. The countenance is pale, bloodless, puffed, 
and oedematous ; the skin is generally opaque, sallow, and inelastic 
to the feel ; the eye is yellowed ; the tongue furred, with a creamy 
slime in the centre ; the pulse feeble, frequent, and peculiarly small; 
the whole appearance is exsanguineous ; the appetite is capricious, 
and the system easily excited by ingesta which are a little stimu- 
lating ; the alvine discharges are clay-like, or else of a dark liquid 
character, and always very offensive ; the urine is deficient in quan- 
tity and tinged with bile ; perspirations are easily induced, and of a 
fetid character ; the epigastrium and hypochondria are tumid and 
tender to the touch ; the respiration is short ; and the whole expres- 



396 INTERMITTENT FEVER. 

sion is that of debility and weakness. This state frequently con- 
tinues for years, under greater or less aggravation ; ultimately, 
however, it terminates in dropsy or diarrhoea, which quickly puts 
an end to the sufferings of the patient. 

In hot climates death frequently takes place during the paroxysm. 
In the more temperate, the disease, when of a bad character, is 
prolonged and obstinate, giving rise to visceral disease. This is 
easily understood if the phenomena of the different stages of the 
paroxysm are borne in mind. It is very obvious, from the condition 
of the circulating system during the cold and hot stages, how a long 
continuance of the fever may produce disease of the liver, spleen, 
and pancreas ; how the intestinal canal becomes the seat of severe 
secondary affections ; and how irregularities in the functions of the 
heart and circulating system generally are established, and dropsy 
and other evils follow in the train. In the cold stage there is an 
evident remora of the blood, especially in the veins of the abdomen 
and portal system ; hence arises immediate disturbance in the func- 
tions of the liver, as is fully shown by the dark-coloured dejections 
immediately following an attack. General reasoning sufficiently 
leads to the conclusion that this should be the case, but the fact is 
almost established by the greater derangement in the biliary func- 
tions which takes place in the quartan ague — the type in which the 
cold stage is the longest. In the hot stage the abdominal viscera 
are generally in a state of congestion, and thus prone to take on 
inflammation, and the lesions consequent to it. 

When death ensues, it occurs either from the severity of the 
general disease overwhelming the vital powers, or from these being 
worn out by the effects of some local lesion. Under the former 
circumstances it appears that the annihilating shock takes place 
either in the cold or hot stages, or during the intermission. Syden- 
ham speaks of it as occurring most usually in the cold stage, when 
he terms it "death by paralysis." In the quartan type of ague it 
certainly does frequently happen during the cold fit; not so, how- 
ever, in the others, which constitute the larger number of cases : in 
these it most usually takes place during the hot stage, or, according 
to Dr. Davis, in the period of intermission. 



VI. ANATOMICAL CHARACTERS. 

The morbid appearances most frequently met with in patients 
dying during the course of intermittent fever are, inflammation of 
the serous membrane and substance of the brain, and disease of 
the liver, spleen, and stomach. From the dissections published by 
Bailly, ( Traite Jlnatomico-Pathologique des Fievres Intermit- 
tentes simples et pemicieuses,) it appears that in nearly all he 
examined, the previous existence of inflammation of the arachnoid 
was indicated by the most vivid injection ; in some cases it was 



ANATOMICAL CHARACTERS. 397 

evidently thickened, and as if doubled by sanguinolent false mem- 
brane. In many instances, on cutting into the cortical part of the 
brain, the divided surfaces presented an undue vascularity, being 
immediately covered with an infinite number of small drops of 
blood. In some cases the colour of the cineritious matter is deeper 
than natural, even approaching to a dark reddish gray ; red spots 
are very frequent, and occasionally softening has been observed. 
The vessels of the brain generally are often distended and gorged 
with blood, the lyra especially being fully injected. Serous effusion 
is frequent among the convolutions of the brain; and at times, though 
more rarely, it is found in the ventricles. 

The lungs are generally healthy ; they have, however, in some 
few cases, been seen gorged with blood. The heart has also been 
found distended and flaccid. 

The liver is a frequent seat of lesion. Dr. Davis says, dissection 
has shown that the organs primarily affected are the liver and the 
spleen. In subjects who have expired of this disease, even in its 
early stage, these viscera have always appeared to be materially 
altered in their structure. {Op. Cit.) The liver has been found 
enlarged even to a very great size. Grottonelle relates a case, 
where it had increased to such an extent as completely to mask the 
stomach and intestines, the left portion extending into the hypo- 
chondrium of that side and adhering to the spleen, so that it could 
not be separated without being torn. The structure of this immense 
mass appeared to be, nevertheless, perfectly normal. {Ad acutas 
et chronicas Splenitidis eidemque sitccedentium morborum His- 
torias Animadversiones.) Sometimes the density of its structure 
is increased, sometimes it is diminished ; it is generally found gorged 
with blood, thus presenting a purple or deep black appearance. 
Bailly speaks of having met with it presenting a character as if 
composed only of black blood slightly coagulated, and of cellular 
bands, which alone offered some resistance to the pressure of the 
finger. Where this weak resistance was overcome, the liver was 
but of the consistence of thin jelly ; for the blood appeared effused 
in its tissue, which resembled a pulpy mass, in no way identical 
with its natural parenchymatous structure. In another case men- 
tioned by this physician, the liver was putrid and tubercular. This 
lesion commenced towards the convex part, and extending itself on 
all sides, descended towards its concavity; nevertheless, the greatest 
destruction of texture was on the convexity, the remaining portion 
being engorged and inflamed. Its volume was natural. Occasion- 
ally purulent deposit has been found in the hepatic structure. The 
hepatic ducts are often found injected, thickened and distended 
with a dense, dark-coloured, viscid bile, as is likewise the gall- 
bladder, the inner surface of which is occasionally inflamed and 
ulcerated. 

But of all the lesions which are met with in fatal cases of inter- 



398 INTERMITTENT FEVER. 

mittent fever, those of the spleen are most frequent.* This organ 
appears to be singularly often affected : its most usual character is 
increase of bulk and consistence ; its structure is easily torn, its inte- 
rior being found to be broken down and composed of a blackish- 
red pulpy mass : sometimes it is of a gray colour. Morgagni 
mentions a case in which the spleen weighed eight pounds ; and 
another is related by Bailly, in which it weighed nearly ten, the 
structure being entirely converted into a pulp. [Dr. Copland men- 
tions a case which came under his notice where the weight was 
nearly eleven pounds.] The spleen has been occasionally found 
ruptured by a longitudinal fissure, and the broken down and altered 
tissue in the cavity of the abdomen. In one case there were fifteen 
or sixteen ounces of dark blood, resembling oil, among the intes- 
tines. In this case the spleen was ruptured at its inferior part by 
an opening, the size of a dollar, from which issued a dark puriform 
substance : it was impossible to raise the spleen without breaking 
it *, and it was so diffluent that it separated into two portions, one 
of which, when placed on the table, became flattened like jelly — 
the other remained attached to the diaphragm, which it was neces- 
sary to cut out in order to expose the spleen completely. In volume 
it was not much increased. 

When rupture of the spleen takes place, the grumous blood is 
found in the cavity of the abdomen, sometimes unmixed, at other 
times it is diluted by a sanious bloody effusion, evidently the effect of 
serous inflammation. Dr. Davis speaks of suppuration and ulce- 
ration of the spleen, but does not think that, unless these lesions 
have become established, or that in weight this organ amounts to 
from two to five pounds, they prove the source of much secondary 
disease ; nor does he imagine that this or any other lesion is ever 
the cause of the primary fever. When lesion of the spleen is met 
with in other organs, generally the spleen and pancreas have almost 
invariably undergone some change in structure. 

The pancreas is often hardened, so as almost to resemble scir- 
rhus. 

The stomach, especially the pyloric orifice and great curvature 
is a frequent seat of inflammation, the characteristic appearances 
varying according to its intensity and duration. Similar inflamma- 
tory appearances are occasionally observed in the intestines, but 
more particularly in the duodenum. Intestinal ulcerations are rarely 
seen, unless dysentery have accompanied the fever. 

According to the observations of Morgagni, Sydenham, Prin- 
gle, Bailly, Fellows, Chisholm and Cleghorn, such are the 
appearances observed on dissections in fatal cases of intermittent 
fever. The last-mentioned writer sums up the question by saying, 
" I have examined the bodies of nearly a hundred persons who 

* [The healthy dimensions of the spleen are given by Dr. Piobrt as follows : — 
In its vertical diameter it is from 3^ to 3J inches, and in the transverse 3 inches. 
Its increase of size is usually proportionate in all its dimensions.] 



STATISTICS. 399 

perished in these fevers, and constantly found one or other of the 
adipose parts in the lower belly (the caul, mesentery, colon, &c.) 
of a dark black complexion, or totally corrupted; the vesica fellea 
full and turgid, and the stomach and intestines overflowing with 
bilious matter ; the spleen larger, sometimes weighing four or 
five pounds, and so excessively soft and rotten, that it had more the 
appearance of coagulated blood wrapt up in a membrane, than of 
an organical part. In the cavity of the head and breast nothing 
extraordinary was met with, excepting yellow serum when the skin 
was tinged with the same colour. 

M. Bailly gives the following numerical statement of the differ- 
ent lesions. He found in thirty-three cases more or less extensive 
disease in the brain ; in twenty-two of these there was thickening 
and other marks of inflammation of the arachnoid coat, and in ele- 
ven inflammation of the substance of the brain. In twenty cases 
there was gastro-enteritis, in four gastritis, and in four enteritis un- 
complicated with gastritis. In eleven the spleen was softened ; in 
some instances it was enlarged, one weighing from two to three 
pounds, and another from eight to ten pounds ; in two cases the 
spleen was enlarged and hardened, in three it was ruptured, and 
in one gorged with blood. In two instances the liver was soft- 
ened, in four it was gorged with blood, and in one inflamed. In 
two cases there was pericarditis, in three peritonitis, in one there 
was pneumonia, and in another inflammation and enlargement of 
the parotid. 



VII. STATISTICS. 

As writers on intermittent fever have not generally devoted 
much attention to the statistics of intermittent fever, we are unable, 
from the very few available materials, to present a very satisfac- 
tory sketch of them. Few, however, as they are, they are inter- 
esting. 

[Among the cases of intermittent fever observed by Dr. Mail 
lot, 1582 were quotidian, 730 tertian, and 26 quartan. Of these 
2338 cases, the accession took place between midnight and noon 
in 1652, and between noon and midnight in 686. The greater 
number of accessions occurred between nine in the morning and 
noon. 658 were simple, and 1680 were complicated. In 1078 in- 
stances the intestinal canal was affected: alone in 343 cases; with 
the brain in 686 cases ; with the lungs in 31 cases; with the brain 
and lungs in 13 cases. In 25 cases the spleen alone was diseased ; 
and in one case the peritoneum alone. The brain was affected 
alone in 466 cases; the spinal cord in 1 : the lungs alone in 103 
cases ; and the pleura alone in 5. In one case, a tertian, there was 
angina with the formation of a false membrane, and no other lesion. 
The intensity of all the complications was in direct ratio to the ele- 
vation of the temperature.] 



400 INTERMITTENT FEVER. 

All ages appear subject to this type of fever, though some periods 
of life are more prone to it than others. In infancy it is a very rare 
disease. Schenck relates a case which he terms congenital, in 
which the paroxysm of an intermittent appeared immediately after 
birth ; and Paullini details another in which it appeared in very 
early infancy. (Obs., lib. vi., n. 36.) And Lind, when showing the 
analogy between the intermittents of England and hot climates, 
says, that even infants at the breast are not exempted from it. 
(Diseases of Hot Climates.) 

The type of ague appears greatly to depend upon age. The 
quotidian occurs most frequently in early life or in advanced age, 
while the tertian is rather a disease of adult life, and the quartan 
of adults and the aged. Andral has given the following table, 
showing the ages at which fifty-six cases of intermittent fever oc- 
curred, under the care of Lerminier, in the Hopital de la Charite. 
Of four patients at the age of 15, three were cases of quotidian or 
double tertian, and one of quartan ; of five between the ages of 16 
and 20, four were cases of quotidian or double tertian, and one of 
tertian ; of nineteen between the ages of 20 and 25, ten were cases 
of quotidian or double tertian, five of tertian, two of quartan, and 
two of erratic ague; of fourteen between the ages of 25 and 30, six 
were cases of quotidian, five of tertian, and three of quartan; of six 
between the ages of 30 and 35, three were cases of quotidian or 
double tertian, two of tertian, and one of quartan ; between the ages 
of 35 and 45, there was one case of quartan ; of three between the 
ages of 45 and 50, two were cases of tertian and one of quartan ; 
between the ages of 50 and 55, there was one case of tertian ; be- 
tween the ages of 55 and 60, there was one case of quotidian ; at 
the age of 61, there was one case of quotidian ; and one of tertian 
at the age of 68. On comparing this with other statements given 
by Andral as to the frequency of simple fever, it appears that both 
classes are most common between the ages of 20 and 25-, that con- 
tinued fever occurs most frequently between 15 and 20, but very 
seldom between 25 and 30, which is exactly the reverse of what 
takes place in intermittent fever. Martinet says, at first sight it 
may appear strange that persons from 20 to 25 years of age should 
be so susceptible of these diseases. An adequate explanation of the 
fact, however, is given, as a majority of these cases consisted of 
young persons who had come from the country to seek employ- 
ment in Paris, and were exposed to privations, disappointment, 
fatigue and unwholesome food, the usual predisposing causes of 
fever. 

Sex appears to have no other influence than is to be accounted 
for by the difference in modes of life. The quotidian occurs more 
frequently in women of inactive habits than in men. Sir George 
Baker, in his account of the epidemic in the fens of Lincolnshire 
in 1780-1, mentions, as worthy of notice, that in many families, the 
female servants were nearly exempt from the tertian intermittent, 



STATISTICS. 401 

while very few male servants, especially the labourers in the open 
fields, escaped. 

The constitutional temperament appears to influence very much 
the type of the disease; the quotidian most usually occurs in those 
of a languid and delicate habit, and in whom the fibre is lax and 
but little irritable ; the tertian is most frequent in the robust and 
sanguine, and in those who are liable to derangements of the ali- 
mentary function ; while the quartan occurs in those of phlegmatic 
constitution, in the melancholic, in those whose health is impaired 
by study or intemperance, and in persons subject to hemorrhoidal 
discharges. 

Of the influence of particular occupations little can be said, ex- 
cepting that it is very evident, that those who are working in or 
near the marshes, whence arise the peculiar miasms, are particularly 
prone to the disease. 

Climate appears to exert a very notable influence in warm lati- 
tudes, where observation has amply proved that this class of fevers 
is more fatal than in the temperate and cold. In the former they 
are apt to destroy by the violence of the symptoms during the 
paroxysm ; in the latter they put an end to life by their obstinacy 
and continuance, and by the visceral disease and debility which 
they induce ; situation also affects both the type and character of 
ague. It is particularly a disease of moist situations, a continued 
residence in which frequently converts a tertian into a double ter- 
tian or quotidian. Sir John Pringle says, that ague is ever more 
regular in those situations where the moisture is pure, and unmixed 
with exhalations issuing from organic matter in a state of element- 
ary decomposition. It is not a little singular, however, that during 
the years 1800-1802, when intermittent fever so much prevailed 
in England, while the inhabitants of the high grounds were harassed 
by this fever in its worst forms, those of the subjacent valleys were 
not affected by it. Sir George Baker and Sir Gilbert Blane 
noticed particularly that the people of Boston, and of the neigh- 
bouring fens, were in general healthy at a time when this fever was 
epidemic in the more elevated situations of Lincolnshire. [Select 
Dissections.) 

Season exerts a most undoubted influence ; so much so, indeed, 
that some writers, more especially Sydenham, have been induced 
to found upon the effects it produces a system of classification — 
hence the origin of the terms vernal and autumnal agues. In no 
known country, where intermittent fever prevails, has this influence 
been found wanting. Agues are never found to be equally preva- 
lent at all periods of the year. In temperate climates the order 
which they follow may be stated as follows: — A comparative free- 
dom from disease is enjoyed between the winter and spring quar- 
ters ; shortly after the spring season has commenced, agues make 
their appearance, and continue to increase until immediately after 
the summer solstice, when there is a short period marked by a most 
26 



402 INTERMITTENT FEVER. 

decided decrease of disease, followed immediately by more nume- 
rous and severe cases, which continue during the autumnal equinox, 
but subside towards winter. The quotidian is most prevalent about 
the end of winter and during the spring ; so very generally is this 
the case, that Sydenham says he never saw a genuine quotidian in 
autumn, and doubts whether it ever occurs excepting at the spring 
time. The tertian occurs at all seasons of the year, but it is most 
frequently observed to prevail in the months a little after the sum- 
mer solstice until the winter has fairly set in. In the depth of win- 
ter their frequency is very much diminished ; to a certain extent 
thay again occur towards the spring, and again subside as summer 
advances. Intermittents occurring at this latter season are com- 
paratively mild, while the autumnal disease is often obstinate, and 
gives rise to serious results. The quartan ague may almost be 
termed an autumnal disease, almost universally occurring between 
the equinox and winter soistice. It is rarely or never met with as 
a vernal disease, unless it have been a latent autumnal ague, or is 
consequent upon relapse. Amongst those who suffered from this 
disease during the Walcheren expedition, in the advanced stages 
the influence of the weather was remarkable. (Davis, op. cit.) 
In the beginning of October, when the weather was fine and dry, 
no modification of the disease arose from the complication of acci- 
dental complaints with it. The disease advanced, and its conse- 
quences succeeded in a certain order, its fatality depending upon 
its own force, and the extensive mischief it produced in the viscera. 
In November many inflammatory affections of the lungs and bowels 
-occurred, and sometimes rheumatism ; during the height of which 
?the paroxysms of ague were suspended, but recurred when those 
diseases abated. The intermittent, for a time, gave place to con- 
tinued pyrexia, which in its turn w T as carried off by an accession of 
ague. As in the preceding month, the intermittent offered varie- 
ties in its appearance, depending upon its own character and not 
upon any modification from the weather. At the latter end of No- 
vember, and the beginning of December, accidental combinations 
were less frequent ; still there were some inflammatory affections 
of the throat and chest, which now and then became difficult to 
manage. 

Of the fifty-six cases given by Andral there occurred in January, 
'February, and March, nine (three quotidians or double tertians, five 
tertians and one quartan); in April, May, and June, ten (one quoti- 
dian or double tertian, five tertians, three quartans, and one erratic); 
in July, August, and September, seventeen (ten quotidians, or double 
tertians,-eix tertians, and one quartan); and in October, November, 
and December, twenty (fourteen quotidians or double tertians, 
'three tertians, two quartans, and one erratic). 

Bailly asserts that intermittent fever is entirely confined to the 
human species — the lower animals never suffer from it. In situa- 
tions where ;lhe influences producing this disease prevail, animals 



NATURE. STATE OF THE BLOOD. 403 

in common with man suffer; but the morbid phenomena never 
assume in them the character of an ague — the fever being inva- 
riably a continued one. 

VIII. NATURE. 

The nature of intermittent fever is very obscure. The inquiry 
naturally resolves itself into the consideration of, 1. The proximate 
cause of the paroxysm ; and, 2. The laws which govern its peri- 
odical recurrence. With regard to the former, various theories 
have been formed. Some writers consider that intermittent fevers 
depend on local inflammation of an intermitting character ; Brotts- 
sais ascribes them to inflammation of the mucous membrane of 
the digestive canal ; Mongellaz and Boisseau to inflammatory 
irritation of any of the abdominal organs. To these views it may 
be objected, that the symptoms are not referable to the usual laws 
of local inflammation, as it regards its fixity ; and that, in fatal 
cases, the effects of inflammation are not discoverable by dissection. 
There can be no doubt that, during the paroxysm of ague, conges- 
tion takes place ; but this is not only not identical with inflamma- 
tion, but an effect and not a cause of the paroxysm. 

Again, it has been supposed that the phenomena are produced 
by the influence of the specific causes on some portion (according 
to Hildenbrand, the ganglio-splaiichnic) of the nervous system. 

Some have assumed that intermittents, in common with other 
forms of fever, depend on congestion of the capillary system. It is 
probable that the structural changes which take place in the several 
organs are immediately owing to this cause; and that, during the 
progress of the fever, these vessels are incapable of performing 
their functions ; but it by no means follows, that the action of the 
primary febrile cause is exerted in this system ; and that, if it be 
involved at all, it is only secondarily. As the investigation, how- 
ever, is intimately connected with that of the proximate cause of 
fever in general, we forbear going more at length into this obscure 
subject. 

It would be useless to enter into any discussion on the various 
vague theories which have been proposed with the view of ex- 
plaining the cause of the intermittence of agues. It is much to be 
regretted, that no satisfactory explanation of phenomena so re- 
markable has been given. It, therefore, appears that the nature 
of intermittents, as well as the laws which govern their periodicity 
or intermittence, is involved in the greatest obscurity. 



[IX. STATE OF THE BLOOD. 

From the analyses made by Andral and Gavarret of the blood 
in this disease, instead of being in a state of hypinosis, the blood 



404 INTERMITTENT FEVER. 

exhibits rather a tendency towards hyperinosis. Andral and Ga- 
varret remark that in consequence of the absence of all disturb- 
ance in the normal functions of the organism during the remission 
of the febrile symptoms, it might be concluded h priori that no 
peculiar changes would be exhibited in the blood. The fibrin rises 
a little above the normal average ; the corpuscles, however, with the 
exception of one case in which the bleeding was ordered at the 
commencement of a second attack, fall below the normal propor- 
tion. The blood in most of these cases was, however, taken from 
persons suffering from long standing tertian or quotidian fever. 
The period at which the blood was taken, whether during the re- 
mission, the hot or the cold stage, seemed to exert no influence on 
the composition of the fluid. It will be sufficient to give the 
maxima, minima, and mean of their researches. 

Water. Solid residue. Fibrin. Blood corpuscles. Residue of serum. 
Maximum - - 847<9 221-9 3-8 127-9 910 

Minimum - - 778-1 152-1 3-0 68-8 71-6 

Mean of 7 analyses 811-4 188-6 3-3 104-3 80-0]* 



X. EXCITING CAUSES. 

It has been proved by evidence the most complete, that except- 
ing on very rare occasions, intermittent fever is caused by a mor- 
bific agent which has been termed marsh miasm, or paludal exha- 
lation. Many attempts have been made to arrive at a knowledge 
of the physical qualities of this agent. Moschati and Broschi 
examined the aftnosphere — the former of some very insalubrious 
rice-fields, the latter of an unhealthy spot in the papal states; from 
which it appeared that it contained albuminous flocculi, somewhat 
viscid in appearance, but the nature of which was not understood ; 
and that it possesses a certain weight, as it does not appear to rise 
in the atmosphere, unless mingled with it by currents of air. All 
that is valuable on the constitution of the atmosphere of those 
places where ague is prevalent, may be summed up from the 
results of the extensive investigations made by M. Julia: — 1. 
That the air of these several situations contains the same principles, 
and in the same proportions, as the purest air of the most healthy 
situations. 2. Marsh air contains a principle which eludes the test 
of the most delicate chemical reagents. 3. Though the nature of 
the noxious vapour is unknown, there is reason to believe that its 
pernicious effects depend on a form of vegetable and animal sub- 
stance in a state of decay, or on a solution of these substances in 
air, or on the gases resulting from their decomposition. 4. Experi- 
ment has not yet demonstrated in marsh air the existence of azotic 
gas, carburetted hydrogen, or ammoniacal gas, or any of the gase- 
ous products of decomposition ; and if they are present in this 
* [Simon's Animal Chemistry, p. 247.] 



TREATMENT. 405 

vapour, their quantity is too small to be appreciated. Whatever its 
constitution or essence may be, it at any rate appears evident, that 
in order to its production, there must be present a certain quantity 
of moisture, vegetable or animal matter in a partial state of decom- 
position, and a degree of temperature which may not be termed 
cold ; for we see that it prevails in districts where such conditions 
obtain — in the extended estuaries of rivers, in swamps which pass, 
under the exhaling influence of the sun, into a comparative state 
of dryness, on the banks of rivers subject to floodings, and on low 
flat sea-shores. 

It also appears evident, that the influence of the infected atmo- 
sphere varies in intensity according to its distance from the source of 
miasm. Thus we are often enabled in the vicinity of marshes to 
trace the various grades of miasmatic fevers, from the most violent 
and fatal to the most simple and mild varieties, as we progressively 
remove from the focus of the deleterious exhalations to the circum- 
ference of its influence. It is for a like reason, viz., the intensity of 
the miasm, that on the first appearance of a miasmatic disease they 
are comparatively slight ; while, as the season advances, they be- 
come more severe and fatal, and again gradually diminish as the 
advance of winter controls the elimination of the specific poison. 

It has been observed that in rare cases other causes are the means 
of generating fevers of an intermittent type. Richter speaks of 
its being caused by worms and other sources of intestinal irritation, 
by suppression of the catamenia and habitual discharges. We 
have seen a case of true tertian occurring in a girl of nine years of 
age which was most undeniably referable to fright. Bailly and 
Audouard in France, and Cleghorn and Fordyce in our own 
country, have maintained an opinion, that it is communicable by 
contact: and Dr. Brown says, that cases have fallen under his 
observation which have led him to entertain at least a suspicion 
that such was the fact; and he quotes from Bailly a case which 
he thinks most forcible : — "A lady arrived in Paris with an inter- 
mitting fever, which she had contracted in the country in a marshy 
situation. Scarcely was she cured, when her husband, who had 
never quitted Paris, but who had had the imprudence not to keep 
himself apart from her during her illness, was struck with like 
symptoms, and in a manner altogether similar." 



XI. TREATMENT. 

Before detailing the measures to be adopted in the treatment of 
intermittent fever, it is proper to point out the great importance of 
removing the patient, if practicable, from the situation whence the 
malarious poison has been derived. The difficulty of curing ague 
when the patient is obliged to remain in a malarious district, and 
the comparative ease with which the symptoms are often removed 



406 INTERMITTENT FEVER. 

in a pure air, render it expedient to adopt at once this important 
measure. 

The treatment is divided into that, 1. Of the paroxysm; 2. Of 
the interval ; and, 3. Of the effects or sequelse of the disease. 

During the paroxysm the utility of assisting nature, and of coun- 
teracting morbid action, is plainly indicated. The natural efforts 
are to be assisted in superinducing upon the cold stage a quick 
reaction or the hot stage, and afterwards in converting the hot into 
the sweating stage. The morbid actions to be guarded against are, 
the congestive, inflammatory, and weakening effects, which have 
been detailed above. 

1. In the cold stage warm diluent drinks are to be freely exhibited, 
while the application of warmth to the external surface is to be 
assiduously employed by means of warm clothing, bladders filled 
with hot water, and similar means. Various internal remedies are 
to be administered at the same time. An opiate given a little be- 
fore the accession of the cold stage, or during its continuance, has 
been found most serviceable ; it controls the convulsive shaking, 
quiets the pain, and relieves the mind from the peculiar irritability 
which characterizes this stage. The combination of an antimo- 
nial with the opiate has been found to assist its operation. The 
exhibition of an emetic on the first feeling of languor, followed by 
copious draughts of the warm infusion of chamomile, pennyroyal 
water, or balm tea, has been much recommended ; and there can be 
no doubt that this treatment is generally followed by satisfactory 
results. 

The practice of blood-letting during the cold stage has been 
strongly advocated in recent years, more especially by the late Dr. 
Mackintosh, of Edinburgh.* In those cases where it has been 
employed, there can be no doubt that it cuts short the paroxysm ; 
but, take it in all its bearings, it is not a mode of treatment to be 
recommended. The consequences of its employment may be thus 
estimated : that, though favourable as far as the individual parox- 
ysm in which it is employed is concerned, it is injurious as regards 
the whole disease. Dr. Stokes, after patiently and fairly examin- 
ing the subject, states, that he apprehends an impression will be 
received, certainly against the indiscriminate or even frequent use 
of bleeding in the cold stage of ague. 

[Dr. Twining was a strong advocate of this method. "The 
benefit of bleeding," he says, "in the cold stage of intermittents is 
now so well known in India, that I need hardly say, that in a great 
number of cases it arrests the paroxysm, and is the best mode of 
preventing those ulterior visceral engorgements and indurations, 
which too often prolong the disease till the constitution is ruined. 
The patient should be bled in the recumbent posture, and permitted 
to lie quiet for an hour after the bleeding, and, during the paroxysm, 

* [Morton's edition of Mackintosh's Practice of Physic. Phil., 1844. ] 



TREATMENT. 407 

he should not be heated with too much bed-clothes, but may be 
allowed a blanket in the cold season, or a sheet in the hot wea- 
ther; he should be supplied with a cup of warm tea, or gruel, or 
thin sago, soon after the blood has ceased to flow. By these means 
he will seldom have either a hot or sweating stage, and the^-ma- 
jority of patients who have used a sufficient course of mild pu%a- 
tives before the bleeding will not have a return of the paroxysm, 
provided they are tolerably well furnished with clothing, and not 
exposed to atmospherical vicissitudes."* In this country the prac- 
tice has met with but little favour. Dr. Lee, the learned editor of 
Copland's Dictionary, states, that in former years he practised 
bleeding in the cold stage of intermittents to considerable extent, 
but in the form of the disease which occurs in the northern and 
middle states he found it unnecessary, and therefore abandoned it.t 
How far it is adapted to the congestive variety prevalent in the 
southern sections of the country, is yet to be ascertained. Dr. Bell 
in the Persian epidemic ague, before described, though previously 
prejudiced against bleeding in the cold stage of intermittent, em- 
ployed it with advantage. Less than sixteen or twenty ounces he 
does not think sufficient. At first the blood came out only in drops 
or trickled in a feeble stream, dark, grumous, and coagulating on 
the arm.] 

The late Dr. Kellie, of Leith, made a curious suggestion. From 
certain facts which are detailed in the Medical Commentaries for 
1794, he thought himself warranted in concluding, 1. That, at any 
time during the cold fit of an intermittent, if tourniquets be so ap- 
plied as to obstruct the circulation in two of the extremities, in three 
minutes thereafter the hot stage will be induced. 2. That if tourni- 
quets be applied previous to the accession of the paroxysm, the 
cold stage will be entirely prevented. 3. That where the cold 
stage of an ague is either thus shortened, or altogether prevented, 
the following hot stage is rendered both milder and shorter in dura- 
tion. The compression ought generally to be continued ten or 
fifteen minutes, for the symptoms of the hot stage will thus be 
moderated ; but it ought seldom to be continued much longer, as 
Dr. Kellie observed that when this has been done, the pulse 
which had become fuller, stronger, and slower, became smaller and 
more frequent ; and, when the tourniquets were removed, the rigors 
and successions returned. 

2. On the approach and during the continuance of the hot stage, 
the clothing should be light, the room ventilated, and the surface of 
the body, or rather the arms and legs, frequently sponged with cold 
water. To allay the intense thirst, a plentiful supply of cold acidu- 
lous drinks should be allowed. Opium has been much recom- 
mended in this as well as in the cold stage. Dr. Lind, {Diseases of 
Hot Climates,) to whom the profession is chiefly indebted for the 

* [Diseases of Bengal.] f [Diet, of Pract. Med., vol. i., p. 1093.] 



408 INTERMITTENT FEVER. 

knowledge of its specific action, was induced, after watching its 
beneficial effects when given at other periods of ague, to administer 
it to twelve patients in the hot stage, eleven of whom were imme- 
diately relieved from headache, the fever gradually abated, and a 
projkse sweat broke out; this alleviation of the symptoms was 
soofrfollowed by a perfect intermission. He afterwards prescribed 
it with very beneficial results to upwards of 300 persons labouring 
under intermittent fever, the quantity usually administered being 
fifteen drops of laudanum combined with two drachms of the 
syrup of poppies. 

There are certain cases in which blood-letting, or the application 
of leeches, is required in the hot stage, though much judgment is 
necessary before either is resorted to. Should severe local pain, or 
other symptoms supervene, pointing out the probability of organic 
lesion becoming established, abstraction of blood should not be 
omitted. It must not, however, be employed late in the disease to 
any great extent, otherwise the constitution will be impaired and 
the strength depressed — circumstances at all times to be dreaded in 
these fevers. Epispastics, as derivative applications under such 
circumstances, are only objectionable from occasionally increasing 
the irritation under which the patient labours. 

3. When the hot stage has subsided into a free perspiration, the 
only thing to be done is to encourage the cutaneous discharge by 
tepid drinks until all uneasiness has subsided. As soon as this 
takes place, quiet means should be adopted to check it, for if it con- 
tinue for any length of time, it tends much to weaken the patient ; 
this is most judiciously effected by dry rubbing, and replacing the 
wet with dry clothing. 

We have hitherto been considering the treatment of simple or 
uncomplicated intermittents, from the history of which Dr. Craigie 
has well observed, three points may be allowed to be safely estab- 
lished. 1. That some agues admit of spontaneous cure; 2. That if 
paroxysms are prevented from recurring, the disease is more likely 
to disappear than if they are allowed to recur; and, 3. That if per- 
manent congestion or inflammation of organs is prevented from 
taking place, the disease is much more curable than when either 
ensues. 

4. In the inflammatory forms, a more active plan of treatment 
is required. Blood-letting, when the patient is young and plethoric, 
and moderate purging, are generally necessary ; and should local 
inflammations arise in the head, chest or abdomen, both general 
and local depletion, with such other measures as the circumstances 
of each case may indicate. Though the blood-letting may be per- 
formed with safety and advantage in the hot stage, when the vio- 
lence of reaction is liable to increase the local inflammation, most 
practitioners advise that it should be deferred until the interval, 
unless the symptoms are such, that danger might be incurred by the 



TREATMENT. 409 

delay. In short, the same principles of treatment which experience 
has shown to be best suited to the local lesions that occur in con- 
tinued fever, are applicable to those of intermittent, regard being 
had to the state of the vital powers, the type of the disease, and the 
intensity of the local affection. 

The gastric complication, though seldom dangerous, is perhaps 
the most difficult to manage. It requires the occasional application 
of leeches to the region of the stomach or to the abdomen, followed 
by mild aperients, such as rhubarb and tartrate of potash, mag- 
nesia, or castor oil. If the stomach continue irritable, and ^the 
sickness and vomiting urgent, sinapisms should be applied to the 
epigastrium, and large draughts of thin barley-water, and after- 
wards the saline effervescing mixture, or soda-water administered. 
If necessary, the bowels may be relieved by occasional enemata. 
If the vomiting persist after these measures, opium, combined with 
aromatics, will generally allay it. 

When ague is complicated with dysenteric symptoms, should the 
tormina and bloody or slimy stools resist the exhibition of opiates 
alternated with mild aperients, it will be proper, if the state of the 
pulse require it, to take blood from the arm, or to apply leeches to 
the abdomen, and afterwards warm fomentations, or the warm or 
vapour bath may be employed. A full dose of opium and James's 
powder may afterwards be given. Dr. Craigie recommends char- 
coal in doses of ten to twenty grains, five or six times a day if the 
stomach will bear it, as the most effectual remedy in agues with 
gastro-enteric disorder. 

In the malignant forms of ague, twenty-five or thirty drops of 
laudanum should be given in hot-spiced negus at the beginning of 
the cold stage, and afterwards hot drinks to bring on reaction. In 
the hot stage, diaphoretics and antispasmodics are to be employed. 
The warm bath, or what has been found more serviceable, the 
vapour bath, should be employed ; should the patient be too weak 
to undergo the fatigue of either, the hot air bath may be substituted. 
The sweating stage should be promoted by opium combined with 
antimony in warm negus, according to the state of the vital powers. 
The combination of camphor and ammonia is often very efficacious 
when there is great debility. When local complications arise in 
this form of ague, topical depletion, if the strength will bear it, or, 
if not, the application of blisters or sinapisms to the region of the 
part affected, must be resorted to, while the strength is supported 
by nourishment and cordials. 

[In the congestive form vigorous practice is urgent. Maillot 
gives an example in which 40 grs. of the sulphate of quinine and 
2 drachms of ether were given in 4 oz. of water at two doses, in 
the course of an hour ; a starch opiate injection, with 60 grs. of the 



410 INTERMITTENT FEVER. 

sulphate of quinine and 2 drachms of ether, was ordered at the 
same time, with sinapisms to the legs and blisters to each thigh. 
Under this treatment the patient began to recover warmth in a few 
hours, and the heart to act more forcibly ; but the next morning 
the amendment was so slight, that a sinapism was applied to the 
whole length of the spinal column, and a clyster with one drachm 
of sulphate of quinine, and three drachms of ether administered ; 
reaction followed with recovery. Every effort must be made to 
produce speedy reaction. Stimulants should be freely given — 
brandy, ammonia, and particularly capsicum — both by the mouth 
and rectum ; bottles of hot water, and hot bricks are to be applied 
to the extremities; sinapisms to the trunk and extremities, with 
turpentine fomentations to the chest and abdomen. As the pulse 
becomes developed, this active and violent treatment must yield to 
milder stimulants and diaphoretics. Quinine should be administered 
freely in large doses, by the stomach and in enemata, and it may 
also be rapidly introduced into the system through blistered surfaces, 
produced by the application of ammonia, and by inunction.] 

5. During the intermission the most strenuous exertions to pre- 
vent the recurrence of the paroxysm are to be made. The treat- 
ment recommended as applicable to the paroxysm is essentially 
palliative, while that of the intermission is curative. Experience 
has very fully assured us of the specific effects of certain medicines; 
but we are totally ignorant of their modus operandi. The first thing 
necessary to be done, is to ascertain if there be co-existing organic 
disease, as such complications materially alter the means to be 
resorted to. In simple ague the bowels are to be thoroughly 
emptied ; and as the secretions of the liver are generally deranged, 
four or six grains of calomel, followed by a purging draught, should 
be given, and repeated occasionally, until the alvine secretions and 
the state of the tongue give assurance of the desired effect being 
attained. In this country calomel is rarely administered as an anti- 
periodic; in India, however, according to Mr. Annesley, {Sketches 
of Diseases of India,) large doses, to the extent of twenty grains, 
are administered with the effect of almost immediately suspending 
the ague. We are not, however, inclined to rank it amongst 
the medicines proper to be administered as an antiperiodic ; for, 
independently of its violent and weakening effects upon the sys- 
tem, it is almost invariably found, that, on withholding its admi- 
nistration, the disease returns. Where the ague is simple, or not 
materially complicated by organic lesion, after the prima? vise 
have been well evacuated, those medicines which are so essential 
to the cure of agues, and are known by the name of antiperiodics, 
are to be administered. We shall now proceed to mention some 
of the more important : — 

The exhibition of emetics is frequently of very signal service ; 
administered about three hours before the expected period of 



TREATMENT. 411 

attack, it invariably mitigates, and sometimes entirely supersedes, 
the paroxysm. Pringle, however, says, that ipecacuanha alone is 
not adequate to produce this effect ; and that it is necessary to com- 
bine with it one or two grains of the tartar emetic. 

Fowler's mineral solution (the Liquor Arsenicalis of the Phar- 
macopoeia) has long been in estimation from its power of arresting 
this as well as other periodic diseases. In the fenny districts of 
England its specific effects are well known j it is there constantly 
used under the empirical name of Tasteless Jlgue Drop. This 
medicine, administered in doses of five or six drops, every four or 
five hours during the intermission, often puts a stop to ague. It 
may very frequently be employed, when quinine and other prepa- 
rations of cinchona disagree. Dr. Brown says, that an extensive 
experience leads him to give it a general preference over crude 
bark, but he thinks it inferior to quinine, though, under certain 
circumstances, it may supply its place ; moreover, it may be given 
in a more inflammatory state of the system than is compatible 
with the safe administration of quinine. It has also been found 
that when an individual, who has been cured of ague by the sul- 
phate of quinine, or any preparation of bark, suffers a relapse, the 
same medicine proves inadequate to restore him to health : under 
such circumstances arsenic will very generally effect the cure. 
[Arsenic has proved eminently successful in the treatment of inter- 
mittent in the hands of many physicians where bark and its pre- 
parations have failed. It has been recommended in the agues of 
children. The late Dr. Dewees mentions the case of a child only 
six weeks old, who was affected with a severe tertian, which was 
cured by arsenic. A fluidrachm of Fowler's solution was diluted 
with twelve fiuidrachms of water, and six drops of this were 
given every four hours.* Professor T. D. Mitchell, of Transyl- 
vania University, speaks highly of its efficacy in intermittent fever, 
and thinks that it may be safely and advantageously administered 
in doses of from fifteen to twenty drops three times a day. It is 
safer, however, not to commence with a larger dose than five drops 
twice a day, watching carefully the effects. Dr. Pereira says that 
it is not necessary to intermit its use during the febrile paroxysm, 
he having repeatedly seen it given with the best effects during the 
paroxysm. Dr. Macculloch states that one-sixteenth of a grain of 
white arsenic, given three or four times a day, will cure intermit- 
tents when the liquor potassas arsenitis fails. t Dr. Boudin, a 
medical officer of rank in the French army, who had opportunities 
of studying miasmatic diseases in France, Germany, Spain, Greece, 
and Algeria — employed arsenic to a great extent in the cure of 
marsh fevers, and has arrived at the conclusion that arsenious acid, 
properly prepared, preserves, in the microscopic dose of the hun- 

* [Phil. Journ. of Med. and Phys. Sciences, No. xiv., p. 187.] 
f [An Essay on Remittent and Intermittent Diseases.] 



412 INTERMITTENT FEVER, 

dredth of a grain, all its medicinal efficacy. He states, moreover, 
that he has often obtained, by a single dose of the hundredth of a 
grain of this medicine, the entire removal of fevers contracted in 
Algeria and Senegal, and which had previously resisted means of 
various kinds, including the sulphate of quinine, and change of 
climate. He believes that though the efficacy of both arsenic and 
quinine is subordinate to the reigning medical constitution, the 
former is to a much less extent, for nothing was more common 
than to find the arsenic successful in cases which resisted the qui- 
nine. Dr. Boudin thinks it of great consequence that the doses 
should be administered always five or six hours before an ex- 
pected paroxysm. He abstains from giving the medicine on the 
days of apyrexia, as useless, and if, after two or three successive 
administrations, no effect is produced, he resorts to quinine. In old 
and obstinate intermittents it may be continued for a longer time. 
The preparation which he prefers is the arsenious acid.* Professor 
Dunglison states that he permanently cured several cases of 
quotidians and double quotidians by sulphate of quinine used 
simultaneously with arsenic, after they had resisted the former 
alone.t] 

Sulphate of zinc has been administered by many practitioners 
with the most beneficial results. The usual dose is four or five 
grains in the form of a pill, every four or six hours. Sir James 
Macgrigor gave it to the soldiers in the Peninsula to the extent of 
half a drachm daily. Dr. Hendy, while residing at Barbadoes, 
employed the white oxide ; and he states, that in doses from two 
to five grains, every six or eight hours, it removed agues which had 
resisted bark and other remedies. 

The Artemisia Absinthium (salt of wormwood), in doses vary- 
ing from one scruple to two drachms, has, according to M. Murs, 
been administered with very salutary results. It was given before 
the paroxysm, or immediately on its accession. From the experi- 
ence which this practitioner had of the effects of this remedy, he 
concludes that it ought to be regarded as at least equal, if not 
superior, to bark. 

The acetate and citrate of ammonia have also been employed, 
but with various success. Such has also been the result of trials 
of the salts of iron, and the whole range of bitter astringent woods. 
To enter upon a discussion of this class of medicines would be 
tedious and unprofitable. We shall therefore mention one only, 
the Peruvian bark, the effects of which upon intermittent fever 
have been marked by the most satisfactory results. As much of its 
efficacy appears to depend upon the quantity administered, it has 
always been an object to devise such means and such combinations 
as render it most grateful to the stomach. It may be administered 
in the forms of decoction, tincture, extract, or powder; the latter 

* [Traite des Fievres Intermittentes, &c. Paris, 1842.] 

f [Medical Examiner, vol. vii., p. 28, and Practice of Medicine, vol. i., p. 434.] 



TREATMENT. 413 

appears generally to have been preferred in doses of from ten grains 
to two drachms. The mass thus swallowed, has, however, gene- 
rally proved very embarrassing, not only from the quantity of 
woody indigestible fibre thus thrown into the stomach, but from 
its occasional nauseating effects. To the credit of modern science, 
these difficulties have been surmounted : in the sulphate of quinine 
we possess all that is curative in this remedy. This most elegant 
preparation is safe and powerful in its effects ; administered to the 
extent of three to five grains every two, three, or four hours during 
the intermission, it rarely fails soon to arrest the progress of the 
fever. Some physicians have administered it to the extent of 
twenty grains at a dose, and have by this means succeeded in 
putting an immediate stop to the disease. In some persons qui- 
nine produces uneasy sensations in the stomach ; this effect, how- 
ever, is speedily counteracted by the addition of a few drops of 
tincture of opium. [The mode of administration of quinine, 
adopted by the late Dr. Eberle, and which he states to have 
invariably proved successful, was to allow the paroxysms to run 
on to the fifth or seventh day, when he found that a few doses of 
quinine put a permanent stop to their progress.* The writer pre- 
fers giving a large dose of quinine (from ten to twenty grains) 
within an hour of the expected paroxysm. He has rarely failed 
to arrest the paroxysm by this means. Where there is irritability 
of stomach, quinine will not be borne in these doses, and there are 
idiosyncrasies which but ill tolerate it at any time. In such cases 
no preparation which the writer has used has more pleased him 
than the cold infusion of the red bark [Cinchona Rubra) made by 
displacement."!"] 

The salt of the willow bark {Salicine) has lately attracted atten- 
tion. In its effects it appears very nearly allied to the quinine, and 
though not equally efficacious, may yet be regarded as a very valu- 
able substitute for it. [Piperin, obtained from the black and long 
pepper, has been recommended by the Italian physicians as little or 
not at all inferior to quinine, but increased experience does not 
seem to corroborate this statement. The antiperiodic power of 
the Tela Jiraneve, (the web of the common black cellar spider) 
has been vaunted by many. Dr. Robert Jackson considered it as 
superior to bark or arsenic in the cure of intermittents. Dr. Con- 
die [Watson's Practice, 2d ed., p. 477) has found it to promptly 
suspend the paroxysms, as "effectually, certainly, as quinine ; in a 
few cases, however, it failed." Beeberine is the latest substitute 
for quinine which has been proposed. It is the salt extracted from 
the Noctandra Rodici, and has been found by Dr. LoganJ to 

* [A Treatise on the Practice of Medicine. Philada., 1835.] 

j- [Red Bark^i; add sufficient water, acidulated with f^i of dilute sulphuric 

acid, to displace f^vj. Of this infusion as much may be given in the. course of 

the day as the stomach will bear.] 

t [Ed. Med. and Surg. Journ., April, 1845.] 



414 INTERMITTENT FEVER. 

possess antiperiodic properties of a high order, and to cost half as 
much as quinine. He records the experiences of Dr. Watt of 
Demerara, and Dr. Nicholson of Madras, both of whom have 
exhibited it in intermittent fevers of various intensities, and who 
concur in the statement that while it is as efficacious, it is free from 
the unpleasant consequences which supervene on the use of qui- 
nine. The ferrocyanuret of iron has been placed by Dr. Stokes 
after quinine and arsenic in efficacy for the cure of intermittent 
fever.] 

In the inflammatory forms of ague, and when there exist acute 
local inflammations, blood-letting should always precede the exhi- 
bition of quinine or other remedies of this class ; and as a general 
rule, the state of the internal organs should be carefully watched 
during the disease, that suitable measures may be adopted, as those 
local derangements materially interfere with the due effects of the 
medicines employed with the view of preventing the return of the 
fit. In all cases of protracted ague in which the intermissions are 
generally, imperfect, it is probable that disease in some important 
organ, generally the liver or spleen, has taken place, which should 
either be removed or alleviated before the antiperiodic remedies 
are resorted to. 

The treatment of the sequelae, or effects of ague, is in general 
very unsatisfactory, as structural changes in the organs previously 
affected have generally taken place. Hence the practitioner has 
often to contend with enlargements of the liver and spleen, and the 
consequent dropsical effusion, or chronic diarrhoea, or dysentery. 

In the consecutive hepatic disease, occasional local depletion, 
followed by blisters or setons, and mercurialization, and afterwards 
the mineral acids, may be cautiously tried. A course of the Chel- 
tenham waters may be useful in recruiting the shattered constitution. 

In cases of enlargement of the spleen, depletions and mercurials 
are useless, if not injurious. More benefit will be derived by a 
combination of quinine and sulphate of iron perseveringly em- 
ployed. The hydriodate of potash in small doses has been recom- 
mended, but its utility is very doubtful. 

The removal of the consecutive dropsical effusions must depend 
on the probability of the organic lesions on which they depend 
being curable : if they are not, we must attempt the palliative 
treatment by diuretics combined with mercurials. 

We have already alluded to the treatment of agues complicated 
with diarrhoea and dysentery, to which we have nothing to add 
here. In all cases the convalescence, and especially the diet, should 
be carefully regulated. The importance of suitable clothing in 
such cases should not be overlooked. 



415 



CHAPTER VII. 



REMITTENT FEVER. 



[Stn - . — Remittens mitis, Febris biliosa, Synochus biliosus ; Bilious Fever, Exacerbating 
Fever, Paroxysmal F., Sub-continual F., Endemic F., Endemial F. of authors ; Fievre 
remittente, F. bilieuse, Fr.; Galenfieber, Germ.] 

Few diseases have acquired so many different names as this 
form of fever. It has been called by the name of almost every 
country in which it occurs endemically : thus we have the Medi- 
terranean, the Walcheren, the Hungarian fever, &c. ; so that, 
without comparing the descriptions of these, we might be induced 
to believe, that instead of one form of disease, there existed many. 
This has led to so much confusion, that it often becomes a source 
of great difficulty clearly to understand the nature of the disease 
which the respective authors are describing. As it is obviously 
most unscientific to designate diseases from the localities where 
they occur, and is moreover very apt to mislead, we shall endea- 
vour, under the term Remittent Fever, to give a succinct descrip- 
tion of the various forms which this disease assumes, premising 
that it appears from the numerous accounts which have been pub- 
lished, to take on in different situations and in different seasons 
very dissimilar characters. These, however, may be referred to 
one of three forms. 1. The Simple; 2. The Inflammatory; and, 
3. The Malignant. 

Remittent fever may be defined to be a disease attended by dis- 
tinct paroxysms of fever alternating with remissions, one paroxysm 
usually taking place every twenty-four hours ; or it may be stated 
as a variety of continued fever, characterized by very evident and 
distinct exacerbations — -in the one respect bearing affinity to inter- 
mittent, and in the other to continued fever. If we regard, how- 
ever, its origin, its associations, and organic lesions, it is evidently 
more nearly allied to the former than to the latter. In many re- 
spects intermittent arid remittent fevers present great general resem- 
blances. They are evidently produced by the same causes, and 
have a tendency to assume the characters of each other; while 
the very marked differences in the accession, duration, and symp- 
toms of the paroxysms, together with the very opposite nature of 
the intervening periods, evidently point them out not to be one and 
the same disease. 

[Bilious remittent fever — a term first used by the late Dr. Rush, 
and now so generally employed to designate the variety of fever 



416 REMITTENT FEVER. 

under consideration — is, after intermittent, the most prevalent type 
in the middle, southern, and western districts of the United States, 
constituting their summer and autumnal epidemic, to which 
strangers, especially residents of the northern states, are so liable 
on their visiting these sections. From its annual presence in so 
large a portion of this country, and its frequent violence, its study 
is one of great interest to the American physician.] 



I. SYMPTOMS. 

Remittent Fever occasionally develops itself without premoni- 
tory signs ; more usually, however, its attack is preceded by a few 
days' ailment, or by symptoms not greatly differing from those 
described as attendant on the forming stage of intermitting fever. 
The more usual symptoms which precede the attack, are, a general 
sensation of weight, followed by languor and lassitude of the whole 
system, sighing and yawning anxiety about the prsecordia, with 
aching pains in the head, back, and extremities, [particularly the 
calves of the legs;] the face is pale, the countenance dejected, 
creeping sensations of cold are succeeded by flushes of heat, the 
appetite fails, the bowels are inactive, and the feces contain a large 
admixture of bile; the tongue is coated, the taste in the mouth is 
unpleasant, [bitter,] and metallic ; the skin is sallow, the eyes be- 
come heavy, the brow clouded, and sleep disturbed by alarming 
dreams. [An indescribable uneasiness about the stomach is said 
by some writers to precede all the other symptoms.] According 
to Dr. Stevens, [On the Blood, p. 217,) there is a morbid action 
in the vascular system, the blood itself being diseased ; which 
deranged state of the vital current is not the effect of either a local 
disease or a nervous impression, but is produced by the direct 
action of a specific poison on the living body, the consequences of 
which are, that the pulse is less frequent than in health, and the tem- 
perature of the blood, and of course of the whole body, is reduced 
sometimes so low as 94°. [The pulse, according to Dr. Bowling, 
is small, but the action of the heart is laboured, and the impulse 
and sounds are increased.] These premonitory signs increase in 
intensity until, the attack of the disease is established; the symp- 
toms of which are considerable aggravation in the pains of the 
back and extremities, at times to such an extent as to resemble 
those of acute rheumatism. [As the hot stage becomes developed, 
the pains in the back and loins frequently abate, and sometimes 
entirely subside ; they may increase again, though in a limited de- 
gree, at the commencement of one or two of the next exacerba- 
tions.] After a general sensation of coldness, rarely amounting 
to a rigor, [and lasting from fifteen minutes to a couple of hours, 
during which there is usually excessive thirst, with nausea and 
vomiting before its termination, a recently eaten meal being gene- 



SYMPTOMS. 417 

rally rejected,] there comes on intense heat, together with tender- 
ness of the epigastrium and right hypochondrium,* the surface of 
the body generally being above the usual standard and dry ; the 
countenance is flushed and excited in its expression ; the eye, 
slightly tinged, has a restless and wild expression ; the head is dis- 
tracted with throbbing pains, [which are generally in the forehead, 
but occasionally in the occipital region;] and in some cases there 
is wandering delirium, [which is most frequently associated with a 
drowsy stupor, being manifested when the patient is half awake, 
and passing off when he is completely roused;] the pulse is fre- 
quent, [generally during the first paroxysm rising to 120 or 125,] 
sometimes small and irregular, at other times full and forcible, but 
rarely hard or tense ; the mouth and throat are dry and clammy ; 
the tongue furred, white, and sometimes brown, [though it may 
remain moist and almost entirely natural ;] the respiration is hur- 
ried, oppressed, and anxious; thirst is considerable, but not urgent;! 
for the most part there is nausea, which is often attended by watery 
or bilious vomiting; the bowels are generally torpid, but if acted 
on, the discharges are either black or green, and exceedingly offen- 
sive ; the urine is scanty, [muddy,] and tinged with bile. These 
symptoms usually continue with varying intensity for some hours, 
ranging from five to ten, and closely represent the hot stage of a 
febrile paroxysm. 

The febrile paroxysm is superseded by the breaking out of a 
gentle perspiration on the head and shoulders, which sometimes, 
though rarely, extends over the whole body, together with a gene- 
ral diminution of the heat and febrile symptoms. Nevertheless, 
there is by no means a state of apyrexia ; there is yet much quick- 
ness and irritability about the pulse, with some slight elevation of 
temperature ; and in place of the intense pain of head, sensations 
of giddiness, tinnitus aurium, lassitude, and tired feelings of the 
limbs. This state, which is termed the remission, continues usually 
for about two hours, rarely more than three, when the febrile 
symptoms recur, and gradually increase until they have acquired 
their former, or even a greater degree of intensity ; and, after 
having continued for a certain period, generally more protracted 
than that of the first paroxysm, again subside into the remission. 
[In the subsequent exacerbations there is an aggravation of all of 
the symptoms of the initial paroxysm, except the chill, which is 
rarely well marked, when the form has been purely remittent from 
the beginning, though slight shivering often precedes the second 
or third, or even the fourth or fifth exacerbations. When there is 
a recurrence of the chills, Dr. Stewardsox thinks that it is most 
commonly at the tertian period. On this point Dr. Bolixg says : 

[Dr. Bolixg observes, that he has rarely observed moderate pressure to pro- 
duce pain in the right hypochondriac region. The left hypochondriac region is 
painful on pressure when the spleen in enlarged.] 
f [In this country the thirst is generally excessive from the very first paroxysm.] 
21 



418 REMITTENT FEVER. 

" Where the fever is of the double tertian type, the first and third, 
perhaps the fifth exacerbation may be ushered in by tolerably dis- 
tinct agues, while the second and fourth may be preceded by but 
the very slightest sensation of coldness, if any." The pulse in 
each succeeding paroxysm becomes more frequent ; if it was very 
full or firm at the commencement these characters may slightly 
increase in the first few paroxysms, but in the majority of cases 
there is a gradual diminution in fullness, until convalescence begins. 
In the subsequent remissions a corresponding increase in frequency 
will be observed, and though relatively to the preceding exacerba- 
tion the pulse shall have fallen, it will still be quicker than during 
the former remission. "In the second exacerbation," says Dr. 
Bowling, "the moisture about the tongue is slight, though it is 
not, properly speaking, dry. In the third or fourth, it is apt to 
become dry, at least on the dorsum, though the edges remain 
moist; and still later, it becomes parched, rough, and cracked. 
With each succeeding exacerbation, also, as it becomes dryer, the 
colour becomes darker; from the natural colour or a dirty white, 
through all the intermediate shades, up to a dark brown, nearly 
black, receiving a modification in its tints, as has been before ob- 
served, from the matter ejected from the stomach. It also becomes 
intensely red at the edges, contracted and sharp pointed. During 
the remissions, the dryness and other marks of the exacerbations 
abate somewhat, and so much is this the case, that in the remis- 
sions following the earlier exacerbations, in which the tongue was 
dry, it becomes moist and nearly natural ; and one not accustomed 
to the treatment of remittent fever, is surprised to find the tongue, 
that but an hour or two before was dry, parched and pointed, moist 
and relaxed, and the same in a short time again presenting the pre- 
vious characters in an increased degree. In each remission there 
is a tendency in the tongue to assume a more natural appearance, 
but in each succeeding one this is less nearly approached than in 
the preceding ; so that although, in any given remission, its appear- 
ance will have improved upon what it was during the exacerba- 
tion which preceded that remission, it will be worse than during 
any former remission. Of course, from the time that the case 
becomes decidedly benefited by medicine, although the exacerba- 
tions may not be immediately arrested, this increasing dryness, 
&c, of the tongue with each exacerbation ceases, or becomes less 
marked. In the first exacerbation of cases, not of a very severe 
character either, the tongue will sometimes be found dry, parched 
and fissured on the dorsum, although it may become less so, or 
even quite moist in the next exacerbation. In these instances, the 
first exacerbation has probably supervened soon after the stomach 
had been loaded with indigestible food, which fortunately is gene- 
rally rejected before the next exacerbation. There is this differ- 
ence between the appearance of the tongue to which I have just 
alluded, and that which becomes dry gradually in the progress of 



SYMPTOMS. 419 

the case : the former retains its natural size and shape, while the 
latter, as already observed, becomes narrow, sharp, and contract- 
ed.' 5 * The salivary secretion, often diminished or even suspended 
during the exacerbations, becomes free during the remissions, but 
less and less so with each succeeding one. The disgust for food 
from the commencement is usually extreme, but is said by Dr. 
Bowling to be much less marked in negroes than in whites. The 
thirst is excessive throughout the disease, there being a constant 
craving for cold or acidulated drinks. In the first remission this 
sometimes abates, but in the subsequent ones is as urgent as during 
the exacerbations. Distressing and constant irritability of stomach 
is a prominent symptom, increasing with each paroxysm. The 
matter vomited is bile, which at first is yellowish or greenish, "and 
at length becomes of a dark grass green, and small in quantity, 
most frequently only sufficient to give a bluish-green tinge to a 
glass of water that may have been retained longer than usual. In 
severe cases, bilious matter, at least in any considerable quantity, 
soon ceases to be thrown up, and the matter ejected, independent 
of medicines, and such fluids as may have been recently swallowed, 
is composed of a tough, glairy fluid, the most tenacious part of 
which, containing suspended in it small, dark, bluish-green flocculi 
— at other times a greenish-brown, dirty-looking sediment — sub- 
sides and adheres to the bottom of the vessel. As the disease 
advances, although the efforts to vomit become more incessant, the 
matter vomited diminishes in quantity, so that frequently, in hours 
of straining and retching, nothing is thrown up but the fluids, &c, 
recently swallowed." 

Stewardson, Ferett, Dickson, and authors generally, repre- 
sent the bowels as costive, but Dr. Boling thinks that in the 
cases he has met with there is a decided tendency to diarrhoea, and 
that purgatives should be cautiously administered after the first 
two or three paroxysms. After the operation of the first purgative 
but little fecal matter is observed in the evacuations, they being 
chiefly serous, containing bile of yellow or greenish colour, though 
sometimes they are clear and transparent. Lumbrici are frequently 
discharged from the bowels, particularly in children. Delirium 
rarely occurs during the earlier paroxysms, and when it does it is 
mild and temporary. When it is established later in the disease it 
may persist during the remissions, though usually abating. It is 
rarely violent. The mind seems occupied with the ordinary asso- 
ciations of the patient. Chisholm says : — "A man much involved 
in debt is incessantly arranging with his creditors. A soldier talks 
of the duty he has to perform, and ever and anon expresses his fears 
of the officer's displeasure. A sailor in like manner is engaged in 

* [Observations on Remittent Fever as it occurs in the Southern parts of Ala- 
bama. By War. M. Boling, M. D., of Montgomery, Alabama. (Am.Journ. Med., 
Sciences, April, 1846.) This is an excellent paper on the symptoms of remittent 
fever.] 



420 REMITTENT FEVER. 

maritime affairs."* The perspirations during the remissions are 
less and less marked as the disease advances. The skin assumes 
frequently, at an advanced stage of the disease, a yellowish tint, 
which is most frequently first noticed in the conjunctiva. Suda- 
mina are met with in protracted cases ; no eruption has ever been 
observed in this type of fever, though genuine petechias occur in 
the malignant forms. 

"The sensation of debility is extreme, and is frequently as much 
complained of in the first or second exacerbation as later in the 
disease, when the actual debility is much greater. At a time 
when a patient will make complaints of the greatest debility, let it 
become necessary for him to get up, or assist himself in any way, 
and he will do so without any call for aid ; or if he does demand 
it, will show himself at the same time capable of considerable mus- 
cular exertion. It is only in very protracted cases — and few such 
occur in this part of the country — that the patient requires much 
assistance in performing any necessary movements, provided he is 
sufficiently sensible to be aware of what is necessary."!] 

In this way the disease proceeds through a regular succession of 
febrile paroxysms, or rather exacerbations and remissions, until a 
critical discharge, which most commonly is a profuse perspiration, 
takes place. This is the commencement of convalescence. 

According to Dr. Jackson, a favourable termination of this 
nature is frequently noticed to occur on every seventh day. He 
has almost invariably observed that the critical perspiration has 
supervened on the seventh, fourteenth, twenty-first, or twenty- 
eighth day. 

Should this series of events not take place, however, the fever 
becomes more uniform in its course, and assumes a character which 
is fraught with much danger. When this is the case, it is not unfre- 
quent that, after the second paroxysm, the phenomena of the dis- 
ease become more obscure, and terminate in remissions which are 
much shortened in duration, and attended by a more marked febrile 
character than was the case on the first or second remissions— the 
exacerbation of the fever itself being in every respect more intense 
and greatly aggravated, in many respects partaking of the symp- 
toms observable in extreme cases of typhus. The surface of the 
skin assumes a yellow hue, and maintains an excessive tempera- 
ture, feels dry and harsh, and occasionally covered by a clammy 
sweat, especially towards the head and shoulders, but which by no 
means gives relief to the urgency of the symptoms. The counte- 
nance is flushed and swollen ; the eyes are prominent, glistening, 
and wild ; the whole expression is one of extreme anxiety and dis- 
tress. The headache is intense ; there is frequently delirium, and 
occasionally in the paroxysms of pain the patient emits piercing 

* [Manual of the Climates and Diseases of Tropical Climates.] 
t [Boling, loc. cit.] 



SYMPTOMS. . 421 

shrieks. The pulse is very varying, now it is full and bounding, 
at one time small and feeble, at another quick and sharp. The 
tongue becomes covered with a yellow viscid mucus; the bowels 
are tender to the touch, and distended by flatus ; the stools are 
fetid, sometimes passed unconsciously; [the nausea is distressing, 
and the vomiting incessant, there being scarcely any interval 
between the spells ;] there is retention of urine, and constant rest- 
lessness with watching. As the disease progresses, the state of 
excitement subsides into stupor and insensibility ; the tongue be- 
comes coated with a thick, black, dry fur ; the pulse fluttering ; the 
respiration heaving and laborious, with subsultus tendinum; and 
the patient gradually sinks into a complete and ultimately fatal 
coma. 

Such is the general view of the simple remittent fever as it 
occurs in temperate climates. The exacerbations in their periodi- 
cal recurrence usually assume a double tertian or quotidian type ; 
the former is stated to be the most frequent; for notwithstanding 
the exacerbations occur every day, yet it is very evident that they 
are more severe in their character on the alternate days. What- 
ever be the type of the remittent, the remission almost invariably 
occurs towards morning ; while, in double tertian, the exacerbation 
takes place towards noon, and in the quotidian type some hours 
earlier, usually about nine or ten o'clock. [Dr. Boling says, 
that " at whatever period of the day the first exacerbation may 
occur, there is a tendency in the subsequent ones to manifest them- 
selves in the after part of the day, say some time between noon 
and six o'clock in the evening, and so strong is this tendency that 
in most of the cases in which the exacerbations anticipate, the first 
will be found to have occurred after this period, and in nearly all 
in which any of the ea?ly exacerbations are deferred or protracted, 
the first will be found to have occurred before this period. In 
fevers of the double tertian type, however, the exacerbations will, 
in a large majority of cases, be found to occur alternately in the 
fore and after part of the day." Dr. Swett found the exacerba- 
tions to come on generally about four o'clock in the afternoon and 
continue during the night, during which time the pulse would rise 
to 112 or 116, while in the morning it would be found from 96 to 
100.] Unless the disease is disposed to terminate favourably, the 
alternating of the period of remission with the exacerbation is 
rarely perceptible after the twelfth day. The remissions, to say the 
least of them, are very obscure. The patient exhibits a continued 
state of lethargic drowsiness, attended by a torpid condition of the 
whole body ; the bowels refuse to act unless by the aid of power- 
ful medicines, the stools being of a most unhealthy black nature ; 
aphthous ulcerations of the mouth and fauces take place, a state of 
things which is quickly followed by the typhoid stage of remittent 
already described. [Dr. Dickson observes, that "it is not uncom- 
mon, especially among the most perfectly acclimated adult natives 



422 REMITTENT FEVER. 

resident in malarious localities, and strangers long familiarized with 
our atmosphere, to find bilious remittent lengthening itself out to a 
tedious protraction ; the patient sinking after the tenth or twelfth 
day, into a low state of fever, resembling the less severe grades of 
typhus, and hence obtaining among us the designation of the 
typhoid stage of bilious fever. Here the well-marked lines which 
separate the period of exacerbation and remission are almost 
effaced; the characteristic periodicity almost obliterated, the fever 
degenerates nearly into the continued type ; and the patient, in the 
language of the older practitioners, " wades through" the attack 
with no definitively regular changes observable from time to time, 
until by the success or failure of our efforts in his behalf, he re- 
covers or is lost."* Dr. Svvett found the remissions in many 
cases by no means decided, and in some not more so than in con- 
tinued fever, the two classes of patients being carefully compared 
at the same time; "so that the physician who should attempt to 
find his diagnosis of the two diseases in the character of the remis- 
sions only, would not unfrequently find himself without a sure 
guide."t] 

Sometimes remittent fever makes its first appearance under the 
form of a regular tertian ague, and is so little distinguishable from 
it, that doubt may be entertained as to its nature, until after two or 
three paroxysms are passed over, when the symptoms together with 
the order of their recurrence, sufficiently develop its true character. 
In fact it is doubtful whether it may not really be originally a true 
tertian ague, converted under the peculiar circumstances into remit- 
tent fever. 



II. VARIETIES. 

The simple form of remittent fever is subject to many variations, 
according to age, constitution and locality ; but as these almost in- 
variably, quickly pass into and assume all the characters of the 
inflammatory or malignant types of the remittent disease, and of 
which we shall presently treat, we shall not further allude to them. 

One variety, however, which occurs to strangers entering a 
country where remittent fever is endemical, and which Dr. Copland 
terms the bilio-injlammatory remittent, must be noticed here. 
Pringle [Diseases of the Jlrmy), when speaking of the diseases 
which occurred in the cantonments in Dutch Brabant, gives a very 
full description of this as it occurred there. — The patients were 
suddenly attacked by ardent fever accompanied with the most in- 
tense headache, and generally with delirium. Should this not take 
place, and they continued sensible, the patients complained of severe 
pain in the back and loins, intense thirst, burning heat and oppres- 

* [Dickson's Practice of Physic, vol. i., p. 290.] 
f [Am. Journ. Med. Sciences, Jan., 1845.] 



VARIETIES. 423 

sion about the prsecordia, nausea, and occasionally, in some cases, 
severe retchings and vomitings of bile; while in others the bile was 
discharged by stool, or accompanied by tenesmus and pains in the 
abdomen. The pulse is described by Mr. Lander to be at first 
small and not quicker than natural, but to rise after bleeding: this 
alteration in the pulse Dr. Craigie attributes, however, to the natu- 
ral course of the disease. This form of the fever generally remitted 
from the beginning, upon bleeding and free evacuation of the 
bowels ; but if these measures were omitted, it was apt to take on 
the continued form, and to assume the typhoid character. In some 
cases, however, though they were speedily and freely bled, yet in 
an hour after, so great was the cerebral excitement that high deli- 
rium ensued ; and, after continuing for some hours, subsided on the 
coming on of a profuse sweat, under which all the other symptoms 
either abated or vanished. Next day, about the same time, the 
paroxysm returned, and in six or seven hours ran the same course. 
In some, the paroxysms were less distinct, the hot fits longer, fol- 
lowed by imperfect sweats, which afforded but slight relief. Some- 
times, indeed, the remissions were so imperceptible, that the fever 
appeared almost continued in its character, while the nearer it ap- 
proached this last state, the more intractable it became. But when 
the paroxysms were distinct, with a remission of some hours be- 
tween them, the patients for the most part did well, however great 
had been the cerebral excitement during the exacerbation. After 
the accession of a few paroxysms the strength of the strongest men 
was so reduced, that they were scarcely able to stand. In those 
who had been ill about three weeks, and without any well-marked 
remission, the fever ended occasionally in quotidian paroxysms ; but 
in these cases there were usually gentle sweats, or rather a continued 
moisture on the skin. In some cases the critical sweats, which 
generally occurred about the ninth day, were profuse and very 
offensive, after which the disease took on the form of a regular 
intermittent. In others, the crisis took place by stool, or by an 
abundant flow of urine. 

Dr. Stedman and Mr. Lander mention as a characteristic of 
this form of remittent fever, that the delirium was attended by 
attempts at self-destruction. That some became delirious without 
any previous complaint, and would have thrown themselves out of 
the window, or into the water, if not restrained. This frenzy 
continued for some hours, when falling into profound sleep, they 
awoke quite sensible but with violent headache. Drs. Brown 
(Cyc. of Prac. Med.), and Jackson [Sketch of Febrile Diseases), 
have paid particular attention to this symptom. The former says, 
that, instead of the ordinary form of the febrile delirium, in which 
the mind appears occupied by a crowd of unconnected ideas, and 
quite abstracted from surrounding objects, it in this case retains all 
its acuteness of perception and vigour of reasoning ; but there is one 
erroneous impression so firmly fixed, that no argument can shake 



424 REMITTENT FEVER. 

it, and that it is frequently of so gloomy a cast, as to impel its victim 
almost irresistibly to suicide. In cases where it occurs, the intellect 
is by no means obscured ; on the contrary, it is often accompanied 
by an elevation of the mental faculties : nor is it symptomatic of 
any peculiar bad state of the system, nor is it proper to the advanced 
stages of remittent fever ; on the contrary, it is more frequently 
observed at the very commencement of the disease, when the facul- 
ties, both mental and bodily, are as yet but little affected. It is 
generally observed in those whose minds have been disciplined by 
education, and have accustomed themselves to the exercise of its 
faculties : it may therefore be regarded as a morbid exaltation of 
them, depending on the general excitement to which the system is 
subjected during the febrile exacerbation. Dr. Brown says that 
no decided peculiarity has been detected in the symptoms during 
life, or in the structural changes discoverable after death, to explain 
the striking discrepancy from the ordinary form of delirium which 
occurs in these cases. In all of them there has been evident derange- 
ment of the digestive canal and its subsidiary viscera ; and this 
derangement, in general so apt to produce mental despondency, is 
acting on a sensorium enfeebled and irritated by fever : but the 
same circumstances exist in other cases, in which there is either no 
aberration of mind, or in which, if it exists, it assumes the ordinary 
febrile form. We are therefore compelled to suppose, that some 
peculiarity of individual constitution co-operates with the disease 
in engendering this unusual form of delirium ; but there is conside- 
rable difficulty in discovering in what this individual peculiarity 
consists. A tendency to actual insanity certainly will not explain 
it, for delirium has borne this appearance in individuals who have 
at no other period of their lives manifested any indications of that 
malady, and the mental illusions always cease on the subsidence of 
the fever. 

The inflammatory form of remittent fever in many respects re- 
sembles the simple, excepting that there is a general aggravation of 
the symptoms, especially of those connected with the circulation. 
This form occasionally shows itself without any previous warning. 
Sometimes the premonitory symptoms are ushered in by a sudden 
attack of the most excruciating headache, which, after it subsides, 
leaves the system weak and overwhelmed with lassitude : in other 
cases they are much the same as is observed previous to the attack 
of ordinary fever, viz., pains in the loins, alternate chills and flush- 
ings of the surface, &c. 

In general the violence of the disease is in proportion to the sud- 
denness and violence of the incursion. (Eberle, Practice of Physic.) 
When the attack comes on gradually, preceded by the usual pre- 
monitory symptoms, the disease generally runs its course slowly. 
When, on the contrary, the invasion is sudden and violent in its 
progress, we may expect the disease to be rapid and violent in its 



VARIETIES. 425 

course. In the milder forms of the inflammatory variety the first 
paroxysm generally is ushered in by a very distinct cold stage, 
which never takes place on the succeeding exacerbations. This 
sensation of chilliness, for it does not amount to a rigor, is succeeded 
by headache of the most violent character, flushed face, suffused, 
and wild expression of the eyes. The skin is generally burning, 
the thirst intense, with loss of appetite, nausea, and strong, full, and 
quick pulse. After a few paroxysms of this kind, a copious dis- 
charge may take place, either by perspiration or by the bowels, 
which proves critical, and convalescence ensues. 

The inflammatory remittents generally, however, present a much 
more severe and dangerous character, and which they assume, 
under circumstances favourable to their development, from the very 
commencement of the attack. When it assumes this severer cha- 
racter, the cold stage is short and by no means severe, it being al- 
most immediately superseded by the febrile accession, which rapidly 
acquires a great degree of intensity. It is marked by an incessant 
and most uneasy restlessness, acute throbbing pain of the head, 
giddiness, excruciating pains in the loins and inferior extremities, 
short hurried breathing, with feelings of the utmost anxiety. The 
face is deeply flushed ; the eyes suffused, and of a dull expression ; 
there is sensation of epigastric fullness, weight, and sickness ; the 
appetite is lost; the tongue furred; the bowels constricted; and 
the urine scanty, high-coloured, and offensive. These symptoms 
continue with varying intensity for nearly twenty-four hours, when 
a remission, always very marked, and frequently amounting to a 
perfect intermission, takes place. This cessation, however, is very 
deceitful ; for, after a very short period, the second paroxysm is 
ushered in with aggravated severity. The restlessness is much 
increased, sleep cannot be procured ; the surface of the skin is 
more intensely hot and pungent to the feel, acquiring that peculiar 
character which has been called calor mordax; the pain of the 
head is most acute, with feeling of constriction, especially over 
the orbits ; the temporal arteries throb violently ; the conjunctiva 
is yellow, and suffused with blood ; the eyes are watery and into- 
lerant of light; the pulse is quick and vibrating; the epigastrium 
oppressed, and more painful on pressure ; the thirst is excessive ; 
and the sickness most deadly, the patient being much harassed by 
the nausea and retchings which are constant ; the bowels remain 
torpid. 

Very often, however, a different state of things obtains after the 
second paroxysm. The symptoms give way to a clammy perspi- 
ration, which is succeeded by an exacerbation, which appears to 
be very much less violent. On this, the third day of the fever, the 
patient is less restless, nor does he complain so much of thirst, 
pain, or heat ; but the skin is generally dry, though sometimes it 
is covered by a clammy perspiration ; the face is slightly yellow, 
with transient flushes passing over it, which, instead of being of 



426 REMITTENT FEVER. 

the bright red colour they were during the preceding exacerbation, 
have rather a dull livid hue, and the pulse is less tense and softer, 
but still frequent. Dr. Stevens says, that if blood be abstracted 
the structure of the red globules will be found to be deranged, as 
is evident from the colouring matter being often detached from 
them and dissolved in the serum, imparting to this principle of the 
blood, when it separates from the fibrin, a bright scarlet colour, the 
colouring matter being so completely dissolved in the serum that it 
cannot be separated, either by filtration or any other mechanical 
means. The tongue is covered with a thick tenacious yellowish 
fur ; the taste is either impaired or so depraved that everything 
seems bitter. This state is viewed by Irvine [Observations on 
Diseases of Sicily) as representing the intermission of a double 
tertian. Though it is often critical, the symptoms afterwards as- 
suming a more favourable character, yet it must not lull into secu- 
rity, as this apparent cessation of severity in the febrile accession 
is often only temporary ; for, in severe forms of this variety of the 
disease, it not unfrequently happens, after this appearance Of com- 
plete remission, that towards evening an end is put to all anticipa- 
tion that the disease has subsided, by an exacerbation taking place, 
in which all the dangerous symptoms are greatly increased. So 
deceitful, however, is this period, that not infrequently it has been 
mistaken for a complete intermission, and tonics and stimulants, 
which have been given with the view of preventing the recurrence 
of the paroxysm, have but tended to increase the severity of the 
disease. 

Burnett {On Mediterranean Fever) has particularly described 
the succeeding stages of this variety of remittent fever when it 
assumes an aggravated form. They are marked by a great in- 
crease of uneasiness and pain about the epigastric region, especially 
on pressure, some patients complaining of a burning sensation ex- 
tending upwards to the throat ; there is great restlessness, with 
oppression about the prsecordia; the abdomen is likewise painful, 
tense, and tympanitic ; the pain of the head becomes more intense, 
attended by wandering or inattention to surrounding objects; occa- 
sionally delirium ensues, which, as the disease advances, passes 
into coma, though the intellect is often to a certain extent retained, 
so that, on being roused, the patient answers questions rationally, 
though, if not disturbed, he lies in a semi-stupid listless state. 
The countenance becomes deeper and more dingy in colour, till it 
is almost brassy and orange-like ; the eye dull and watery, and the 
conjunctiva of a confirmed yellow ; the skin harsh, moist, and 
clammy, exhaling a disagreeable foetor, and at first of a bright 
yellow, but afterwards of a darker hue ; the pulse is irregular, 
sometimes full and tumultuous, at other times it is quiet, small, but 
generally intermitting ; there is incessant vomiting, often of blood, 
succeeded in some cases by a matter resembling coffee-grounds ; 
the stools are frequent, thin, black, fetid, and sometimes glutinous- 



VARIETIES. 427 

like ; and, according to Dr. Craigie, if kept, undergo the putre- 
factive decomposition natural to animal matters. As the disease 
advances in its progress, the remissions are scarcely perceptible, 
certainly by no means so commonly distinct as Cleghorn (Dis- 
eases of Minorca) states them to be. The whole character of the 
disease rather partakes of that of a continued fever : blood exudes 
from the gums and fauces, and hemorrhage to a considerable 
extent takes place from the nose and bowels ; the restlessness is 
increased; the jactitation in the bed being constant, subsultus ten- 
dinum with picking of the bed-clothes ensues ; an irksome pain is 
felt across the pubis, and there is a suppression of urine. In many 
cases there is complete ischuria renalis, and in some the bladder has 
been found distended, so as to require the introduction of the cathe- 
ter ; the stools are passed involuntarily ; occasionally the parotids 
inflame and suppurate ; petechia? and vibices occasionally make 
their appearance ; the tongue becomes coated with a black crust ; 
the teeth covered with sordes; the breathing more laborious, the 
action of the respiratory muscles being very violent ; the anxiety 
extreme ; the pulse intermitting, and so weak as to be sometimes 
scarcely perceptible ; and the whole is finally wound up by cold 
extremities and profuse clammy sweats. Death frequently ensues 
on the fourth or fifth day, more generally on the sixth,seventh, or 
eighth, though occasionally life may be protracted beyond that 
period. 

Such are the symptoms which mark the progress of the inflam- 
matory remittent in its more formidable character, or when it has 
been neglected or ill-treated. It also frequently supervenes on those 
slighter forms which have been previously described ; so that it is 
always necessary for the practitioner to be on his guard, as the ap- 
proach of the severer type is often masked and very insidious, and 
the symptoms often becoming violent and unmanageable, when 
least expected to be so. 

The malignant form of remittent fever is usually preceded by 
peculiar feelings of feebleness and languor, with pains in the loins 
and head, giddiness, with flushes of heat, alternating with sensa- 
tions of chilliness, which terminate, not in a shivering fit, but in a 
general collapse of the vital powers, and an alarming depression 
of the circulating system. This is quickly followed by a period 
of reaction, characterized by the most excruciating pain over the 
eyebrows, and in the head generally, with a peculiar feeling of 
tightness, as if the skull was firmly girt with a cord ; the skin is 
dry, hot, and harsh ; the countenance flushed and of a purple hue, 
has rather a collapsed and harassed aspect, expressive of pain and 
anguish ; the eyes are injected and ferrety ; the tongue is clammy, 
and coated with a whitish yellow fur, sometimes rough, dry, and 
brown ; the pain of the epigastric region severe, with occasional 
bilious vomiting ; the pulse full and frequent, but is neither hard 



428 REMITTENT FEVER. 

nor vibrating ; and the patient feels oppressed, restless, and de- 
sponding. This state continues for about twelve hours, when a 
remission ensues, though the patient yet remains very ill and un- 
comfortable. After five or six hours a slight sensation of cold 
ushers in another paroxysm, in which the symptoms evidently 
assume a more dangerous character; the headache is most excruci- 
atingly severe, attended by transient delirium, and uncontrollable 
restlessness and jactitation ; the collapsed and anxious expression 
of countenance is more marked ; the pain at the pit of the stomach 
is burning and urgent, and much increased on pressure ; the whole 
abdomen participates in this painful tenderness ; the general ex- 
pression of the eyes is glassy and sunken, and the conjunctiva is 
both yellow and suffused with blood ; the skin is of a dusky yel- 
low, and its temperature unequal in different parts; in some, as in 
the preecordial region, head, &c, being intensely hot, while in others 
it is cold and clammy, while its sensibility is so much diminished 
that blisters only produce reddening of its surface ; the breathing 
is short, laborious, and hurried ; the tongue is coated with a dry 
yellow or brown crust; the lips and teeth become thickly covered 
with sordes ; the thirst very intense ; there is nausea, with fre- 
quent vomiting of matter resembling curds and whey, which is 
likewise the character of the copious and frequent stools. Ano- 
ther remission ensues like the former, attended by manifest general 
indisposition and debility, and followed by another exacerbation 
of the symptoms, in which the collapse of the arterial system is 
more marked. The disease now assumes a continued form, and 
in which, as it progresses, the symptoms evince a more dangerous 
character: the restlessness is unceasing; the headache becomes 
of a low nervous character ; the abdomen tumid and painful on 
pressure ; the solids appear to have lost their tone, and feel 
generally flaccid ; the skin is of a dirty yellow colour, and, as 
death approaches, acquires a greenish hue, and in place of the 
usual temperature, is cold, and covered with a clammy exudation, 
which is particularly fetid and offensive ; the vascular reaction is 
very low and imperfect; the pulse is intermitting, small, rapid, 
and fluttering ; the tongue is dry, and covered with a black 
fuliginous coat ; the teeth and lips are thickly incrusted with a 
viscid slime ; the gums are spongy, a bloody sanies exuding 
from their surface ; aphthous spots appear in the mouth and 
throat; the evacuations, which in appearance are black and pitchy, 
are dark and offensive; there is constant vomiting of a dark gru- 
mous fluid ; the secretion of urine is suppressed, or nearly so ; 
delirium, occasionally violent, but for the most part of a low mut- 
tering kind takes place, and is the forerunner of coma which 
almost invariably ensues, while the whole frame is shaken by sub- 
sultus tendinum ; vibices and petechia? make their appearance ; and 
the morbid state of the fluid is further shown in the bloody dis- 
charges which take place from the mucous surfaces of the mouth, 



VARIETIES. 429 

nose, and intestinal canal. The patient gradually sinks, unless con- 
vulsion, as is not unfrequently the case, puts a sudden termination 
to the scene. 

Dr. Clark [On Diseases of long Voyages to Hot Climates) 
describes a variety of this form, which in some respects is yet more 
malignant in its characters. It is ushered in by slight shivering, 
headache, pain and sickness of the stomach, with great precordial 
anxiety and an overwhelming depression of spirits. Sometimes 
without any notice the patient faints, during which the expression 
of the countenance is pale and gloomy in the extreme, a character 
that is somewhat retained after the state of syncope is recovered 
from, immediately after which a large quantity of bile is vomited. 
This period of the disease is particularly marked by nervous timi- 
dity, which continues during the paroxysm ; the pulse is small, 
feeble and quiet; and the pain of the stomach and vomiting increase, 
until the paroxysm has fairly set in ; the countenance is flushed and 
anxious ; the eyes are red, and the headache violent ; the pulse rises, 
becomes full and sharp ; the mouth is dry ; the tongue furred ; and 
the thirst intense ; uncontrollable delirium ensues, which subsides 
on a perspiration breaking out. In the remission which follows, 
the pulse becomes slower and soft, but the nervous feelings of 
debility and personal danger remain. This remission continues 
but for a short time, when another paroxysm ensues, attended by 
aggravation of all the symptoms: the fever now becomes continued, 
no trace of intermission being discoverable ; the pulse intermits, is 
small and rapid ; the tongue becomes black and crusted ; the epi- 
gastric pains are excessive ; the stools frequent, fluid, and offensive, 
and voided involuntarily ; coma alternates with violent delirium. 
Tremors, hiccough, vibices, and petechia?, are prominent symp- 
toms, together with a clammy moisture in the skin, from which 
exudes a stinking cadaverous smell. After the third or fourth day 
the patient dies. 

In this variety there is, from the first, a strong impression on the 
patient's mind that the disease will terminate fatally, and this is so 
firm, that no reasoning can alter it. Dr. Brown (Cyc. Prac. Med.) 
says, he does not know whether this is to be considered as a men- 
tal illusion or not, for, in every case which had fallen under his ob- 
servation, the patient's prediction had been fulfilled. It is doubtful, 
whether the mental impression was instrumental in the accomplish- 
ment, or whether it did not itself proceed from some deadly feeling 
of the patient, which language could not express, and of which the 
cause did not display itself by manifest signs. Dissection has thrown 
no light upon this point. 

Such may be considered the more usual forms in which remittent 
fever is met with, when uncomplicated by other diseases. There 
are, certainly, many varieties which occur ; but to enter at any 
length upon them, would occupy more space than our limits will 
permit. 



430 REMITTENT FEVER. 

[A variety of pernicious remittent, is occasionally met with in 
our southern states, which may be called the comatose form, and 
which resembles closely the same variety of pernicious intermit- 
mittent already described. The force of the malarious poison 
seems in such cases to be expended on the great nervous centres. 
Commencing with slight shivering, the vascular reaction soon be- 
comes intense ; the face is full, and flushed ; the pulse firm and 
full, there is strong pulsation in the larger arteries, especially the 
carotids ; deep stupor soon comes on, with dilated pupils, and slow 
and often stertorous breathing. As the paroxysm abates the stu- 
por subsides, and during the remission, which generally lasts but 
for a few hours, no alarming symptom is present. On the return 
of the paroxysm, which frequently anticipates itself, the same train 
of symptoms appear with increased severity. And this is repeated 
until recovery or death occurs. The remissions are sometimes 
very imperfect, and Dr. Boling relates a case of this kind where 
the patient lay eight days comatose. When called to him, he says, 
"he presented all the symptoms of apoplexy, and nothing revealed 
the true nature of the case but a disposition to yawn and stretch 
every morning, continuing from 7 A. M. to 10 A. M., and a slight 
abatement in the force, and a diminution of a few beats in the fre- 
quency of the pulse, with a temporary disappearance of the stertor. 
During the remissions, while yawning and stretching, his appear- 
ance was exactly that of a person just on the point of awaking from 
a sound and refreshing sleep, and the bystanders, even those who 
had seen him several times, could scarcely divest themselves of the 
impression that this was the case, and were in momentary expec- 
tation of seeing him open his eyes and address them. The case 
terminated favourably, the patent waking up during the hour of 
remission on the 9th morning, and required but little treatment 
after." 

A form of remittent fever called congestive, — and styled by Dr. 
Dickson, "a hideous and pestilential modification," — prevails to a 
great extent over a large portion of our northern and north-western 
states, and is frequently terribly destructive. It commences often 
as a common intermittent, and the first paroxysm frequently at- 
tracts but little attention. After an interval of variable length, 
another rigor occurs, which may be prolonged for several hours, 
until reaction or death takes place. This is remarkable for the 
extreme coldness and death-like hue of the face and extremities. 
There is violent gastro-intestinal irritation, with incessant purging 
and vomiting. The discharges are often mixed with blood, and 
rarely with bile. Dr. Parry, of Indiana, says that they have " the 
appearance of water, in which a large portion of recently killed 
beef has been washed."* There is but slight abdominal tender- 

* [Am. Med. Journ., July 1843. This is an admirably written paper on the 
Congestive Fever of Central Indiana, by Dr. Charles Pahry, of Indianapolis.] 



COMPLICATIONS. 431 

ness, but a sense of weight, and burning heat in the stomach are 
complained of. The thirst is intense, and unquenchable. The 
respiration is peculiar; it is described as consisting of "a deep 
drawn double inspiration (or double sigh), with one expiration;" 
the patient complains that he cannot get his breath. The pulse is 
small, thready, and frequent, beating from 120 to 140 in a minute ; 
it sometimes becomes imperceptible for several hours before death, 
though generally, it is to be felt to the last. The body is bathed 
in a cold, clammy sweat, occasionally limited to the face and neck 
— the skin being of a livid hue and shriveled. There is usually 
excessive restlessness, the patient continually tossing about, and 
endeavouring to get out of bed. In many instances the brain is 
undisturbed, the intelligence remaining until death. In some 
cases there is severe cephalalgia and even delirium; and in others 
coma makes its appearance early in the second paroxysm. If no 
abatement in these symptoms occurs, death takes place in from 
twenty-four to sixty hours, the patient expiring in great agony. If, 
however, the remedies have acted, the restlessness diminishes, the 
skin dries, the pulse falls and becomes developed, and the body 
gradually attains its natural temperature. Dr. Wharton, of Mis- 
sissippi, observes that " this is a very slow process, as it often re- 
quires from twenty-four to forty-eight hours for the heat to travel 
from the knees to the extremities of the toes."* Dr. Boling 
asserts that "notwithstanding the small and thready state of the 
pulse, in this variety of pernicious fever especially, the action of the 
heart will be found strong, as indicated by the loudness of its sounds, 
and the force of its impulse."!*] 



III. COMPLICATIONS. 

It is necessary to keep in view the great liability of this disease 
to become complicated with organic lesion. This is almost univer- 
sally the case in the inflammatory and malignant forms. The 
symptoms which have been detailed as characterizing these, show 
evidently that there is always present much functional disorder of 
the liver, alimentary canal, and brain ; and we find it is in these 
organs that lesions are most ordinarily met with. As the occur- 
rence of these is one of the chief causes of fatal termination, the 
importance of being aware of their presence is obvious. | At the 
same time it must be understood, that in describing thenvwe are 
not alluding to that condition of remittence which so often occurs 
in acute and febrile diseases. The copious details of the different 
forms of remitting fever which have been given, render a length- 
ened detail of its complications unnecessary. 



* [The Congestive Fever of Mississippi, with cases. By R. G. Wharton, M. D., 
Grand Gulf, and Am. Journ. Med. Sci., April 1844.] 
f [Boling, loc. cit., p. 109.] 



432 REMITTENT FEVER. 

When the mucous surface of the stomach becomes inflamed, 
independently of the usual heat, pain, and tenderness, being much 
aggravated, there is a constant craving pain, increased on pressure, 
and which is continued during the remission. The tongue is cover- 
ed with a thick yellowish layer of mucus, subsequently becoming 
brown and cracked, with dry fiery edges. There is general loss of 
appetite, or rather a disgust of every kind of food. If the aliment- 
ary canal participates in the inflammation, and which it usually 
does, the abdomen generally is painful, distended, and tympanitic ; 
the stools are watery, and resemble in appearance the washings of 
flesh ;: the urine is turbid and yellow. The dysenteric symptoms 
which show themselves so often in the advanced cases, may be 
referred to this cause. 

When the structure of the liver participates in the mischief, there 
is severe pain and tenderness of the right hypochondrium, with a 
pulsation there and on the epigastrium, which Mr. Cartwright 
describes as equal to that which the heart produces in the tho- 
rax, and synchronous with the pulsations of that organ. There is 
also excessive irritability and spasm of the stomach ; the febrile 
heat is intense ; at first the tongue is clean, but afterwards it be- 
comes coated with a brown fur ; there is great torpor of the bowels, 
incessant sickness and vomiting, at first of a very small quantity 
of glairy fluid, without admixture of bile, but subsequently of a 
dark grumous fluid, which is likewise the character of the frequent 
copious motions which supervene on the previous state of costive- 
ness. 

When the brain or its membranes are affected, the excitement 
during the exacerbation is characterized by delirium, which alter- 
nates and eventually passes into coma. The fever under these cir- 
cumstances soon takes on an adynamic character, and a general 
depression of the vital functions early terminates in death. 

M. Baumes also describes remittent fever when complicated with 
pectoral disease. This, however, is comparatively rare. . When, 
however, it does occur, the pleural or bronchitic inflammation im- 
mediately shows itself by the symptoms usually attendant on these 
conditions. [Bronchitis is a very common complication of the re- 
mittent fever of this country. Pneumonia is rarely met with.] 



IV. TERMINATIONS. 

Remittent fever in all its varieties may terminate in perfect re- 
covery, or be converted into intermittent disease, or superseded by 
other affections. It may terminate in death by syncope, convul- 
sion or exhaustion. Death may ensue either in the first paroxysm, 
in the third, or in any day of the fever subsequent to these. If it 
occur in the first paroxysm, it is usually accompanied by delirium, 
which subsides into a fatal coma ; but if it occur in or after the 



ANATOMICAL CHARACTERS. 4:66 

third paroxysm, it usually takes place by fainting or by convul- 
sion, which are attributable to inflammation of the brain ; or it may 
ensue from the weakening effects of the excessive discharges both 
alvine and cutaneous, or from the abdominal lesions generally, or it 
may occur from general exhaustion of the vital powers. Perfect 
recovery usually takes place between the fifth and eleventh days 
by the supervention of critical perspirations, by critical bilious dis- 
charges, or by the appearance of vesicular and pustular eruptions. 
Sometimes the disease gradually abates after the seventh, four- 
teenth, and twenty-first days. When remittent is converted into 
intermittent fever, the change usually takes place after the third or 
seventh day, taking the form either of quotidian, double tertian, or 
tertian ague. The other diseases which remittent fever usually 
passes into, are such as depend upon lesions of the organs which 
have become complicated with it ; the most usual are, hepatitis, 
chronic disease of the liver attended by dropsy, and dysentery ; be- 
sides which, cases are mentioned of pulmonary disease, permanent 
insanity, hydrocephalus, disease of the kidneys and bladder, toge- 
ther with a tendency to obstinate ulcerations, especially of the 
lower extremities. 



V. ANATOMICAL CHARACTERS. 

The appearances which have been met with after death, in those 
who have suffered from remittent fever, are numerous, and, in many 
respects, not unlike those observable in intermittents. 

The external appearances are, a collapsed state of the body, 
general yellowness of the surface, with here and there livid spots. 
On examining the head, a small quantity of fluid is usually found 
between the cranium and dura mater. The dura mater is inflamed 
and its vessels are turgid ; the vessels of the pia mater are particu- 
larly so ; and between it and the arachnoid, masses of coagnlable 
lymph are often deposited. The ventricles are frequently distended 
with serum, and the choroid plexus is deeply injected. Burnett 
says, that the thalami and corpora striata have a firm glandular 
consistence. In the cavity of the chest inflammation of the pleura, 
with serous effusion and adhesions, and inflammation of the bron- 
chial membrane, with an engorged state of the parenchymatous 
structure of the lungs, are met with. The heart is usually flaccid 
and easily torn. In the abdomen, the liver is found enlarged, in- 
jected, and softened in structure, and is generally of a dark, some- 
times of a gray colour. [The investigations of Dr. Stewardson, 
of Philadelphia, led him to believe that the essential anatomical 
character of remittent fever was a peculiar alteration in the colour 
of the liver, which he thus describes. " This colour more or less 
resembled bronze, or a mixture of bronze and olive, or some shades 
of lead colour. The most correct idea of the colour would per- 
28 



434 REMITTENT FEVER. 

haps be conveyed by stating its predominant character, the same in 
every case, to be a mixture of gray and olive, the natural reddish 
brown being nearly extinct, or only faintly to be traced. This 
alteration existed uniformly or nearly so throughout the whole ex- 
tent of the organ, except in a single instance, where a part of the 
left lobe was of the reddish-brown hue. As the alteration of the 
colour pervaded both substances, the two were uniformly blended 
together, and the aspect of the cut surface remarkably uniform."* 
The observations of Dr. Stewardson have since been confirmed 
by Dr. Swett, of the New York Hospital,t Dr. Howard, of Balti- 
more,;): Dr. Powers, of Baltimore,§ and Drs. Anderson and Frick, 
late Resident Physicians of the Baltimore Almshouse Infirmary. ||] 

The gall-bladder contains a small quantity of inspissated bile, 
which is sometimes very dense and hard. [In seven out of eight 
cases, in which the state of the gall-bladder is recorded by Drs. An- 
derson and Frick, it was distended with thick grumous bile, 
resembling molasses. In the eighth case it was moderately dis- 
tended with straw-coloured bile.] The stomach is usually inflamed, 
especially towards its cardiac orifice, and in many places covered 
with a chocolate-coloured gelatinous matter. The intestinal canal 
presents much the same appearances as the stomach ; occasionally 
there are slight ulcerations. The intestines are almost invariably 
distended by flatus to a most unusual extent. The kidneys are 
frequently inflamed ; the bladder contracted, and its inner surface 
covered with blood. The mesenteric glands and pancreas are 
often enlarged, as is likewise the spleen, which, in its broken-down 
character, resembles the appearances presented in ague. The whole 
muscular tissue is softened, and seems to have lost its tone and con- 
tractility. 

[The glands of Brunner in the duodenum were found by Drs. 
Stewardson, Frick and Anderson, to be unusually developed, 
and sometimes to a remarkable degree. In Dr. Swett's cases 
this condition was not observed. Drs. Stewardson, Gerhard, 
and Swett state the glands of Peyer to have been healthy in all 
their cases ; whilst Dr. Richardson, of New York, says that they 
were diseased in all the cases of remittent fever he examined at 
the New York Hospital, inl840;1F and Drs. Geddings of Charles- 
ton, Vache and Stevens of New York, Harrison of Cincin- 
nati, and Jackson of Philadelphia, particularly mention the fact 
of their alteration in cases examined by them. In Drs. Anderson 

* [Am. Journ. Med. Scien., April, 1841, and April, 1842. Elliotson's Practice 
of Medicine, p. 344.] 

•j- [Am. Journ. Med. Sciences, Jan., 1845.] 

* [Ibid., Jan., 1845.] 

§ IStewakdson's Edition of Elliotson's Practice, p. 345.] 

II [Am. Journ. Med. Sciences, April, 1846.] 

If [New York Journ. Medicine and Surgery, 1841.] 



DURATION. — PROGNOSIS. 435 

and Frick's cases, the agminate glands were generally visible, and 
in several the mucous membrane over them was injected, and 
sometimes softened. Of nine examinations after death from the 
African remittent fever, made by Dr. M'William, in three the 
patches of Peyer were distinct and enlarged.] 



VI. DURATION. 

The duration of remittent fever is influenced by many circum- 
stances, but more especially by the form which it assumes. The 
simple is the most protracted, occasionally extending from two 
diurnal paroxysms to a period of five, six, or even eight weeks. 

The inflammatory form, under favourable circumstances, does 
not maintain its acute character longer than three days, but ulti- 
mate recovery is much longer deferred. In fatal cases death fre- 
quently ensues on the third exacerbation, though it is generally 
delayed until the fifth or seventh day. In the malignant form, 
death has been known to occur in the first paroxysm ; but it is 
usually postponed until about the third or fifth day. In favourable 
cases the convalescence is often very protracted. 



VII. PROGNOSIS. 

The circumstances which indicate a lingering attack, or a fatal 
termination, are symptoms denoting inflammatory complication, 
especially in the brain or its membranes, a depressed state of the 
system, or coma supervening upon delirium. Death may also be 
expected, when the remission is but slightly marked, when the skin 
assumes a deep yellow tint, but especially when suppression of 
urine, diarrhosa or dysentery supervenes. 

A favourable termination may be generally looked for, if, at the 
commencement of the disease, the premonitory symptoms be well 
marked and of moderate duration ; if the headache, pain in the 
epigastrium and prostration of strength be not considerable ; if 
the pulse be soft and of moderate strength, the surface uniformly 
moist and not clammy to the feel ; and if there be absence of severe 
gastric affection, of dyspnoea, singultus, subsultus and the yellow 
colour of the skin ; if the bowels be moderately open and free from 
pain or distension ; if the eyes be not suffused, nor the conjunctiva 
yellow ; if the thirst and other febrile symptoms abate, and more 
especially if the mouth and face become covered with eruptions. 
[Dr. Boling says, that a favourable change is earlier indicated by 
the secretion of the mouth and tongue, than by any other sign, 
" probably because more readily brought under immediate obser- 
vation. Even when the tongue is quite dry during the exacerba- 
tions, a degree of moisture is apt to appear, at least upon its edges 



436 REMITTENT FEVER. 

and lower surface, during the remissions ; and that a favourable 
change is about to take place, or has already done so, and that the 
coming exacerbation will be less severe than the preceding, may 
frequently be inferred from the slightest increase of this moisture, 
during a remission, upon what it had been during the previous 
,one."*] 

The chief circumstance in the history of remittent fever which 
tends to embarrass the prognosis, is the occurrence of the calm on 
the third day already alluded to. Although this almost total inter- 
mission from disease often proves critical, and the forerunner of 
recovery, it must always be viewed with the most careful suspi- 
cion, when it supervenes upon symptoms in any way characterized 
by severity or malignancy. 

The susceptibility to remittent fever appears equal in both sexes, 
and at every period of life ; but males, from their occupation, are 
more exposed to its exciting causes. Soldiers and sailors serving 
in hot latitudes, where the peculiar miasm occurs, are very liable 
to it. Individual constitution exerts great influence, both in 
respect to the primary susceptibility to remittent fever, and the 
character it may afterwards assume. Generally speaking, the 
inflammatory variety prevails in those of a plethoric habit, the 
malignant among the weak and languid, persons of a bilious 
habit, those who are weakened by previous disease or intemper- 
ance, or who have frequently suffered from gastric irritation. 
Climate and situation evidently exert a manifest influence on re- 
mittent fevers. In districts where the miasm is generated, places 
near its origin, or low and ill-ventilated localities, one or other 
form, but more especially the malignant, prevails. In temperate 
countries it usually assumes the simple and inflammatory cha- 
racter. 

Every variety of the disease appears to be most severe in the 
autumn, and to be influenced by changes in the weather ; thus it is 
observed to be particularly severe after a very wet summer ; in a 
hot summer after a wet spring, or during a wet season after previ- 
ous heat. In the tropics it has been frequently noticed to prevail 
epidemically, when the summer has been unusually warm after a 
peculiarly wet season. If the disease occur in the early part of 
summer, the cerebral symptoms predominate ; while after August, 
or during the autumn, the gastro-enteric complication, with tend- 
ency to dysentery, prevails. Dr. Craigie says that in very dry 
summers, where the winds are light and infrequent, and the atmo- 
sphere calm and undisturbed, remittent fevers are more frequent in 
occurrence, more rapid in progress, and more violent in symptoms. 

* [Boiing, loc. cit.j 



NATURE. 437 



VIII. NATURE. 



What has been stated as to the causes, both proximate and 
remote, of intermittent fever, applies in great measure to remittent. 
As regards the proximate cause, those who advocate particular 
theories as to the nature of fever in general, see them illustrated in 
the phenomena of remittents. Cullen, who considers this form to 
be a variety of the intermittent fever, refers its immediate origin to 
spasm of the extreme vessels. Pinel, who believes that remittents 
arise from disease in the capillaries of the brain and stomach, terms 
them meningo-gastric ; while Dr. Craigie, one of the last who 
has followed out this view, says that this morbid action is not so 
exclusively confined to those parts as to justify their being so 
called ; but that the process of remittent fever, whatever it be, is 
evidently diffused over the whole capillary system of the brain, the 
lungs, the alimentary canal, the secreting glands, the liver, pancreas 
and kidneys, as also over the muscles and bones. In short, that it 
is like fever generally — an affection or disorder of the capillary 
system of the whole frame. He endeavours to explain the pheno- 
mena upon the supposition, that although this capillary disorder be 
general, yet it displays its effects more conspicuously in different 
organs at different periods of this disease, and that the stages of 
remittent fever are the result of these changes. {Practice of 
Physic.) 

Dr. Stevens attributes the origin of this fever to a disorganized 
state of the blood, as evinced in its black crimson colour, which he 
states to be a certain proof of the entire loss, or at least of a great 
diminution, of its saline ingredients. It must be admitted that a 
great many of the phenomena of fever cannot be explained upon 
the supposition of local inflammation being its sole cause; and 
accordingly Dr. Stevens has endeavoured to show that in fevers 
produced by marsh miasm, or by contagion, the diseased action in 
the solids is as much the effect of the altered condition of the blood, 
as it is in those cases where fever is induced by injecting a putrid 
or poisoned fluid directly into the circulating current ; and that the 
remote cause first poisons and chills the blood, and after a time 
paralyzes the heart's action, thus giving rise to the cold stage. 
According to this theory, the first link in the chain of morbid phe- 
nomena in essential fevers is, the vitiation of the blood — a condition 
existing even before the attack in all the fevers produced by aerial 
poisons : and that to this cause are also to be attributed the func- 
tional disease in the solids, the derangement in the secretions, and 
the sudden variations in the temperature, not merely of a part, but 
of the whole system. Though Dr. Stevens is perfectly correct as 
to the fact ? that the state of the blood is very different in fever from 



438 REMITTENT FEVER. 

that in health, yet we must repeat our conviction, that there is 
much wanting before his views can be undeniably established. 

From the affinity which remittent disease bears to intermittent, 
there is every reason to believe that they are produced by the same 
remote causes : observation fully justifies such a view ; and all 
writers agree that the remittent fevers arise chiefly from marsh 
exhalations. On the other hand they have appeared during the 
intense heat of tropical climates, and in such instances they doubt- 
less originate in terrestrial exhalations. We believe, however, that 
this origin is less frequent than has been supposed, and that more 
accurate .observation will show, that there are in these localities, 
marshes, undrained sands, or other sources of miasmatic exhala- 
tions, which had been overlooked. It has been remarked, that 
when remittent fevers arise from rapid terrestrial desiccation, they 
are very violent, approaching the malignancy of yellow fever. 

Whatever may be the nature of the specific poison thus exhaled, 
it appears capable of remaining dormant in the system for several 
weeks, and, according to Dr. Stevens, for an incredible length of 
time, even for months, without producing its specific effects. He 
likewise thinks, that it may be neutralized or so altered in its pro- 
perties, as to be incapable of producing its peculiar action on the 
human system. This view is founded on the observation, that in 
the Genesee country, where the inhabitants during the hot months 
are exceedingly subject to violent and often fatal attacks of the 
marsh fever, those persons who are employed in the saltworks 
remain exempt from the marsh fever, although the salt factories 
are situated in the lowest part of an extensive swamp. 



IX. DIAGNOSIS. 

The diseases with which remittent fever may be confounded are 
chiefly the quotidian and double tertian intermittents, the yellow 
fever, and the seasoning fever, of the West Indies. 

The continued febrile condition, and the vomitings and tendency 
to discoloration of the surface, are, however, characters which 
sufficiently enable us to distinguish it from the intermittents ; at 
the same time the passing of the one into the other is so frequent, 
that accuracy in diagnosis is rendered difficult, and not always to 
be relied on. In fact, many authors have described them as varie- 
ties of the same type, as they likewise have the yellow and the 
seasoning fever of the West Indies, between which and the remit- 
tent diagnosis is more difficult. It appears, however, now to be 
well ascertained, that they are distinct diseases ; but this opinion 
has in great measure obtained rather from their general history 
than by any very defined differences in their symptoms. Dr. 
Stevens states, however, that they are totally separate and dis- 



TREATMENT. 439 

tinct from each other, and easily distinguished, particularly in the 
beginning. 

The yellow fever differs in the following particulars :— Though 
the patients may suffer from a sensation of cold, they never shake 
or tremble. The fever is never of one type, but is invariably con- 
tinued. There is an expression of the countenance which is pecu- 
liar to it. Dr. Stevens says, that though it is not so marked as the 
expression in tetanus, it is so distinct, that those who have seen it 
once easily recognize it. The stomach is irritable even from the 
first, and the liver is affected early in the disease ; the bile is pecu- 
liarly acrid, corroding the ducts, and inflaming the intestinal canal. 
There are generally cramps, which rarely occur in remittent dis- 
ease. But of all the distinguishing characters the most certain and 
constant is the black vomit of yellow fever : it is not unlike sooty 
water, a character of vomited matter which never prevails in re- 
mittents. 

From the seasoning fever of the West Indies it may easily be 
distinguished, as this is characterized by having no premonitory 
stage nor cold fit, no inflammation of the stomach or liver, by the 
tongue being clean, and the pulse full and incompressible. That 
these several collections of symptoms to which these different names 
have been given, are essentially distinct diseases, is rendered quite 
obvious when their whole history is taken into consideration. To 
enter upon this would, however, not only be too lengthy for the 
limits proper to the discussion of this disease, but would in great 
measure be otherwise out of place. 

[The diagnosis between remittent fever, and the common type 
of continued fever in this country, is, in general, very easy, even 
when the remissions are indistinct, and the disease is said to run 
into the continued form. The absence of many of the prominent 
and almost distinctive features of the prevalent form of continued 
fever, will usually enable us to make the distinction with certainty. 
In remittent fever there is no eruption, so far as observed, either 
rose coloured or measly, nor any petechias, or vibices; there is no 
constant tenderness, with gurgling on pressure in the right iliac 
region; the intelligence is usually good, and the peculiar besotted 
expression of the face in marked typhoid fever is wanting. The 
absence of these symptoms, with the peculiar features of remittent 
fever itself, will, we think, prevent the two diseases from being 
mistaken.] 



X. TREATMENT. 

The indications of treatment in remittent fever do not materially 
differ from those of continued fever, which have elsewhere been 
fully treated of. The points more particularly to be attended to 
are, the reduction of the general fever, the obviating the effects of 



440 REMITTENT FEVER. 

congestion and inflammatory action in the liver, stomach, and in- 
testines, as also in the brain and its membranes. 

The disease of the general state of the system is to be obviated 
by the prompt administration of purgatives, in order to clear the 
primas viae from the morbid secretions found in the stomach and 
intestines ; the reduction of the over-excited heart's action by blood- 
letting, and the use of medicines of a diaphoretic nature. With the 
exception of some of the French writers, ail practitioners agree on 
the necessity of administering purgatives ; at the same time they 
are to be used with considerable judgment, as much mischief fre- 
quently accrues from their abuse. If violent and irritating cathar- 
tics are too unsparingly administered, they are very apt to set up 
an irritation in the mucous lining of the bowels, which is attended 
by consequences so imminent, as often to be the source of more 
serious alarm than the effects of the disease itself. There can be 
no greater mistake in the treatment of remittent fever, than the ex- 
hibition of a rapid succession of this class of medicines. They tend 
rather, by their local irritation, to increase the acrid nature of the 
secretions. At the same time it is absolutely necessary, especially 
at the onset of the fever, that effective evacuants should be admin- 
istered ; but those selected for this purpose should be but little irri- 
tating or drastic in their operation. The use of purging enemata 
will be found very useful adjuncts to the employment of purgatives, 
but they must by no means be solely relied on ; and where there is 
much gastric irritation, and there are but few cases where there is 
none, a small quantity of the syrup of white poppies should be ad- 
ded, the addition tending very much to allay pain and to soothe 
the system. 

The employment of mercury has been much canvassed by prac- 
titioners ; the greater number recommend its employment, but the 
extent to which its exhibition has been pushed by some, we feel 
persuaded, cannot be advantageous. Dr. Eberle (Practice of 
Physic), however, who for more than fifteen years employed this 
remedy in nearly every case of remittent fever that came under his 
superintendence, administered it very freely during the two or 
three first days after the attack. Though he states that a gentle 
mercurial impression is beneficial, he condemns strong mercuriali- 
zation or ptyalism. In the great majority of the cases he treated, 
he found all the symptoms of the disease abate, often very con- 
siderably, as soon as the mercurial influence became evident, and 
that in many instances a speedy convalescence ensued. To obtain 
these results the calomel should be early and regularly administered, 
and continued until slight manifestations of its specific influence on 
the system have become evident by soreness of the gum, when its 
use must immediately be suspended. Many, however, are much 
more strenuous advocates for its exhibition ; but even those agree 
in condemning its use except in the earlier stage. (Ferguson, 
Med. Chirurg. Trans., vol. ii.) After the fifth or sixth day its 



TREATMENT. 441 

constitutional operation is obviously productive of mischief. As 
calomel is very apt to produce active purging, it is generally ad- 
visable to combine with it a small quantity of opium, perhaps the 
Dover's powder is the most advantageous form. We should 
strongly recommend, that unless there be signs of congestive or 
inflammatory action present, calomel as well as active purgatives 
should not be resorted to. The thin, watery, muddy, reddish, and 
fetid stools, the tympanitic and tender state of the abdomen, and 
the cerebral irritation which frequently occur in the latter period 
of the disease, are very generally the results of the frequent use of 
active and irritating cathartics. The course to be pursued in re- 
spect to the use of this class of remedies, is to exhibit on the very 
commencement of the disease an active purge, either, the extract 
of colocynth by itself or combined with mercury, followed by the 
mildest evacuants, so as to produce two, certainly not more than 
three, evacuations in the twenty-four hours. This action should be 
gently maintained during the progress of the fever, and, for this 
purpose, Seidlitz powder, small doses of Epsom salts, castor oil, or 
rhubarb, are the most convenient. The employment of a mix- 
ture composed of magnesia and castor oil has been much recom- 
mended. It is made by mixing very intimately an ounce of the oil 
with a drachm of the carbonate of magnesia, with the addition of 
about an ounce of any of the usual syrups: of this a quarter part 
is to be taken every hour, or every two hours, until the bowels are 
moved. 

The use of emetics has been much approved of by some prac- 
titioners, but the majority are decidedly averse to them. They 
appear peculiarly liable to upset the stomach, a condition which is 
apt to supervene without any cause of this kind, and is at all times 
very alarming and difficult to control. The too common result of 
their employment, during the first stage, is to set up a gastric irri- 
tability, and in the more advanced stages to increase the tenderness 
and tympanitic tumefaction of the bowels. Under such circum- 
stances the disease is apt to run a tedious course, the abdomen 
remaining sore on pressure, and the alvine discharges often becom- 
ing watery, reddish, and irritating, in their passage through the 
lower bowel ; in short, there is every manifestation of great irrita- 
tion, if not of inflammation, in the intestinal mucous membrane. 
Lind is decidedly opposed to their employment, and states he can 
assert with confidence, that when given in doses which produce 
full vomiting, they are attended by the most unfavourable effects, 
headache, vomiting, and all the local affections, being much aggra- 
vated by their use. They seldom or never succeed in removing 
nausea, or in producing a critical perspiration; but, on the con- 
trary, appear to hurry on, with greatly increased gastric irritation, 
the second stage of the disease. 

Blood-letting formerly was esteemed, if not a very injurious 
mode of treatment, at least to be very equivocal in its effects. In 



442 REMITTENT FEVER. 

the present day blood-letting, both general and local, is almost in- 
variably resorted to. For an appreciation of the true value of this 
remedy we are greatly indebted to Dr. Irvine, who published the 
results of this mode of treatment in the cases of remittent fever that 
came under his observation in the Mediterranean. These results 
were most satisfactory. The statements of Sir William Burnett 
are also highly confirmatory of its being a most valuable mode of 
treating this disease. He says, that in the first stage of the disease, 
the inexperienced or inattentive observer is too apt to be led astray 
by the prostration of strength, the watery eye, the oppressed pulse, 
the anxious look of the patient, and the disposition to syncope on 
abstracting a few ounces of blood from the arm. The disease, 
however, is at this time a purely inflammatory one, and easily 
managed: blood-letting, both general and local, should therefore be 
resorted to, and repeated according to the urgency of the symptoms. 
It will often happen, after a few ounces of blood have flowed, that 
syncope will be induced : this must not prevent the repetition of 
the bleeding as long as the symptoms in any way indicate that it is 
required. In the course of an hour after the fainting is recovered 
from, it may generally be repeated even to the extent of thirty or 
forty ounces without again producing it. He moreover affirms {op. 
cit., p. 21) that syncope is less likely to occur when the blood is 
taken from the temporal artery ; a mode of abstracting blood he 
particularly advocates. He states that he has often seen a bleeding 
of thirty ounces from this artery, aided by a brisk purgative, put 
an end to the disease ; the headache, if not entirely removed, being 
greatly ameliorated ; and that in many instances so immediately, 
that the patient has declared he felt the pain escaping with the 
blood. If before this evacuation the pulse should have been op- 
pressed, it will rise under the lancet, and patients who have been 
carried, so great has been the apparent debility, have, after the loss 
of the thirty ounces of blood, risen and walked about, expressing 
their surprise at their former condition. The relief thus obtained is 
not in all cases permanent; the patient must be carefully observed, 
and on a return of headache, increased vascular action, heat, or 
other symptoms of pyrexia, the lancet must again be resorted to. 

Though bleeding is now universally allowed to be a judicious 
operation in remittent fever, yet it must be borne in mind that age, 
constitution, and climate, modify very much the extent to which it 
is to be pursued. This is, however, so obvious, that it scarcely 
requires being alluded to. It may nevertheless be not out of place 
to observe that the English, who visit countries where it is ende- 
mical, and there become subject to the influence of remittent fever, 
bear, for the most part, abstraction of blood to a much larger ex- 
tent than is usual in the natives themselves ; and also, as a general 
law, that in very dry climates it is a safer remedy than in the 
humid. 

To obtain an uniform perspiration is of the utmost import- 



TREATMENT. 443 

ance. At least such is the view we entertain, though it is opposed 
to that of Burnett, who states that sudorifics have never appeared 
to him to be attended with the smallest advantage, especially when 
employed in the early stage. He says, that it is well known to 
every practitioner, that they often fail in inducing perspiration, and, 
under such circumstances, their general action cannot but be highly 
unfavourable ; and, at the commencement of the disease the patient 
is often covered with a profuse perspiration, from which he derives 
no relief. We cannot but view this statement as overcharged and 
erroneous. Most writers agree that saline draughts, the acetate of 
ammonia, and medicines of that class are eminently useful, espe- 
cially when the warm or tepid bath, or even cold sponging, is 
employed to aid their effect. These may be employed according 
to circumstances, with the best effects, especially if, after due evacu- 
ation, an undue vascular action, with headache, remains. Con- 
nected with the subject of saline medicines, we must mention the 
plan recommended by Dr. Stevens. It consists in the free use of 
neutral saline salts, those which he more particularly recommends 
being the carbonate and chlorate of potass. There can be no 
doubt that these are of great service, but scarcely, in our opinion, 
Jo the extent which he has been led to imagine. 

If the disease show disposition to localize itself, depletion and the 
application of counter-irritants should immediately be resorted to. 
Should the stomach or bowels be the chief seat of irritation, a large 
poppy-head poultice will often give speedy and permanent relief. 
In addition to these, mild diluents should be freely allowed. 

Such, then, is the general line of treatment to be followed in the 
first stage. As the disease advances, however, the remedial means 
which have been hitherto employed must in a great measure be 
desisted from, or, at least employed only with great caution. To 
the local affection the attention of the practitioner, in the after 
period of the disease, should in a great measure be directed, as from 
it most usually the severity of the symptoms proceeds. The topi- 
cal application of leeches, or a blister to the neighbourhood of the 
affected organ, should be resorted to, and tepid bathing and saline 
remedies at the same time employed, together with the administra- 
tion of saline draughts, or of the neutral salts. 

Should the disease, notwithstanding the means pursued, arrive 
at its third and most dangerous period, little more is to be done than 
to keep up the strength of the patient by such diffusible stimulants 
as are usual in the last stage of typhus fever. Ammonia, combined 
with aromatic confection, has been particularly recommended under 
these circumstances, as have also musk and valerian ; these latter 
remedies we believe to be very valuable. The oil of turpentine, 
in doses of thirty drops, is perhaps one of the most safe and useful 
medicines in this stage ; it often immediately controls the character 
of the symptoms, and changes entirely the nature of the alvine 
secretions. In this stage the patient may be allowed anything he 



444 REMITTENT FEVER. 

may desire, in the way of nourishment or stimulants, as sago, 
arrow-root, spiced wine, porter, brandy. &c. The camphor julep 
is said to be very useful in allaying the singultus, which is so pain- 
ful a symptom in the closing scene. 

Such is the general sketch of the treatment which experience has 
taught to be most useful in remittent fever. It would have been 
out of place to have gone very minutely into a discussion upon it, 
as in a great measure it is similar in its essential details to that pur- 
sued in ordinary continued fever. 

When a complete remission is procured in the early stage of the 
disease, and this is followed by convalescence, it must be borne in 
rnind that though a very urgent desire for food immediately takes 
place, it cannot with safety be indulged; indeed, the convalescence 
of no disease is so likely to be retarded, as that of remittent fever, 
by injudicious or excessive diet. The most proper is that which is 
mild and nutritive, and not that which is stimulating. It is but 
rarely in the first days of convalescence that wine or bitter infusions 
are required. 

Before concluding this sketch of the treatment, it will be neces- 
sary to say a few words on the use of those tonics, the employment 
of which in intermittent fever is so beneficial. Their employment 
in the treatment of this disease has, however, excited much differ- 
ence of opinion. Some practitioners, amongst whom are Lind and 
Clark, have advocated the use of bark immediately after the remis- 
sion has set in, while others, among whom are Johnson and Bur- 
nett, most strenuously condemn it. The former speaks most de- 
cidedly, affirming that the exhibition of Peruvian bark, while 
symptoms of pyrexia remain, has been attended by the most mis- 
chievous effects. He says, that, under its use, the mortality has 
been great, relapse frequent, and dysentery almost universal, in 
those who had the fever in a severe form; nor was there an instance, 
when given during the supposed remission of the symptoms, where 
it prevented a return of the paroxysm. Too often this medicine 
has been given with wine at the commencement of remittent fever, 
the consequence of which has been, that the tongue has put on a 
brown, dry, and furred appearance ; the anxiety, delirium, and 
irritability of stomach, have been much increased, while the whole 
train of nervous symptoms have soon become formidable, resisting 
every means of alleviation, till death has put a period to the suffer- 
ings of the patient. 

[In the treatment of remittent fever in this country, the simple 
expectant plan is the one which has been generally of late recom- 
mended by those who have had much experience in the disorder 
General blood-letting is in most cases not required, particularly in 
our southern latitudes, where great caution is required in its use ; 
it is, however, said to be better borne by northerners in such cases, 
than by the native inhabitants. When decided indications exist for 
the use of the lancet, — general arterial excitement, as shown in the 



TREATMENT. 445 

wild bright eye, intense cephalalgia, hard, full pulse, hot surface, 
and injected face — it should promptly be resorted to, and great 
relief will frequently follow ; but it will rarely be found necessary 
to repeat it. Local bleeding, on the contrary, is most generally of 
great utility, in relieving many of the prominent symptoms, — as the 
gastric irritability, tenderness or pain of the epigastric and hypochon- 
driac regions, and the pains in the back. Emetics are now gene- 
rally abandoned in the treatment of this form of fever, it being found 
that they aggravate the gastric distress, which is usually so annoying. 
If, however, it is found necessary to empty the stomach at the com- 
mencement of an attack, the mildest means that will effect the ob- 
ject, should be resorted to. A full dose of calomel (grs. x.) may 
be given in the first paroxysm, followed by castor oil, or a saline 
cathartic. No benefit can be derived from a course of systematic 
purging afterwards, and much harm may result. It is important, 
however, to keep the bowels open with mild laxatives, care being 
taken to select those which may not offend the stomach, and by ene- 
mata. As to the specific influence in this disease of mercury, no 
satisfactory evidence has, in the opinion of the writer, been ad- 
duced of its utility. Small doses of calomel, blue pill, or hydrar- 
gyrum cum creta, combined or alone, may be highly useful as ad- 
juvants in the general plan of treatment, as in that of other diseases. 
The apartment of the patient should be kept cool, and he should 
not be oppressed by too much covering to his bed. Cold sponging, 
with water, or vinegar and water, is generally excessively grateful, 
when the sldn is hot and dry. Dr. Dickson speaks highly of the 
effects of cold water, and particularly of the cold affusion, which 
he is disposed to regard as among the most efficient of our febrifuge 
remedies. « All that we can hope or anticipate from blood-letting/' 
says he, " may be obtained in a majority of cases by the use of the 
bath, while the latter possesses this striking and obvious advantage, 
that we can repeat it as often as the symptoms are renewed that 
require it. Nor can I help expressing my surprise at the very 
limited resort of my professional brethren to it, when I consider 
how instinctively we desire it as a relief from the burning heat that 
oppresses us, and how certain and immediate a means it is of af- 
fording this relief. Of the three modes of employing it, affusion, 
namely, immersion and ablution, the first is the most impressive and 
efficacious, the last the least liable to objection or risk in doubtful 
^cases. The particular indications which demand the resort to it 
'unhesitatingly, are found in the youth and general vigour of the 
patient, and the heat and dryness of the surface. The local deter- 
mination which it controls most promptly is that to the brain, shown 
by headache, flushed face, red eyes, delirium, etc., with a full, hard, 
bounding pulse. Seat your patient in a convenient receptacle, and 
pour over his head and naked body from some elevation, a large 
stream of cold water ; continue this until he is pale, or his pulse 
loses its fullness, or his skin becomes corrugated, and he shivers. 



446 HEMITTENT FEVER. 

On being dried and replaced in bed, a genial sense of comfort and 
refreshment will attest the benefits derived from the process, which, 
as I said above, may be repeated whenever the symptoms are re- 
newed, which it is so well adapted to remove. If the shock of this 
shower bath or cataract be too great, immersion, which many pre- 
fer, may be substituted. Few shrink from this, and almost every 
one will evince the high gratification and enjoyment derived from 
it. One of the pleasantest effects following the bath, is the complete 
relaxation of the surface which it so often brings on, attended with 
a copious and salutary sweat. I need not warn you against the 
nearly obsolete practice of endeavouring to accelerate or increase 
this by wrapping in blankets or shutting up the apartment, or warm- 
ing it artificially. The patient is to be covered agreeably to his sense 
of comfort; and though I would not place him in a current or 
draught of air, I would have his chamber fully and freely venti- 
lated. Some have strangely enough imagined it to be necessary that 
evacuations of some kind should be premised to the application of 
the cold bath, but this is a worse than superfluous caution. It does 
positive harm by postponing the remedy until the time of its most 
special adaptation and greatest utility is past — the earliest and form- 
ing stage of the febrile attack. It is here, I repeat, that you will 
find it most admirably beneficial. Yet you will meet with frequent 
occasion to advise its repetition at intervals, throughout the whole 
progress of the disease ; and even when the patient can no longer 
bear either affusion or immersion, he will often be relieved and grati- 
fied, by washing and sponging him, especially over the hands, arms, 
breast, feet, and legs. In the very latest stages of our worst fevers, 
ablution in this way with ardent spirits, is found singularly refresh- 
ing. The affusion of cold water locally upon the head in a stream 
of some height, by the spout bath, is of inestimable advantage in cases 
where the cerebral determination is inordinately violent, dangerous 
or tenacious; and will bear to be repeated faroftener than it would 
be proper to take the patient out of bed for the administration of 
the general bath. Support him in a leaning posture over the bed- 
side and dash the current from a pitcher over the vertex for some 
minutes and from some elevation above him. Many Avho dislike 
all the other modes of using cold water, entreat for this operation 
as the most soothing of possible indulgences ; nor have I yet met 
with any ill consequences from allowing its most unlimited fre- 
quency of repetition. The cold bath in its several modes of gene- 
ral application is prohibited, let me remind you, when the patient is* 
of feeble habit of body ; much advanced in age ; much exhausted 
or enfeebled at the time ; when the pulse is weak, or the skin cool, 
or covered with moisture; when the lungs are oppressed or inflamed; 
and when diarrhoea is present. Its repetition is forbidden when it 
has occasioned a protracted chill or rigor, or the patient has con- 
tinued to feel cold or uncomfortable from it." Excessive irrita- 
bility of stomach is a frequent and very troublesome symptom. Ice 



TREATMENT. 447 

in small pieces, the effervescing mixture, and other remedies of this 
kind may be administered for its relief. To moderate the excessive 
thirst, ice, iced water, and acidulated drinks may be allowed. 
Lemonade, tamarind water, and a weak solution of cream of tar- 
tar, are, in general, very grateful. With regard to the administra- 
tion of quinine some difference of opinion prevails. As a general 
rule, the more decided the remission, the greater its utility; in 
the inflammatory form, it is generally of little advantage. Where 
the remissions are well marked, or where there is a tendency to 
prostration, it is, on the contrary, of the highest value, and should 
be administered in doses of from five to ten grains, frequently re- 
peated before the anticipated exacerbation. Stimulants sometimes 
are necessary towards the termination of the disease. Of these, 
capsicum, wine, brandy, and ammonia, with infusion of serpentaria 
or valerian, and nourishing food, are very beneficial. Convales- 
cence should be carefully watched, as relapses are easily induced 
by imprudence. The diet should be digestible and nutritive, and 
the body should be well guarded against any vicissitudes of climate. 
The secretions generally should be attended to, and moderate exer- 
cise prescribed with the returning strength. The mild bitters will 
often materially assist us in restoring the powers of the stomach. 

The congestive form of remittent fever requires prompt and 
vigorous treatment. The chief indications are to procure reaction, 
and to prevent a recurrence of the paroxysm. To effect the first, 
sinapisms should be applied over the stomach, chest, between the 
shoulders, and on the extremities. Blisters are recommended by 
some practitioners as preferable, whilst others advise that they 
should replace the sinapisms, when these have commenced to excite 
irritation of the surface. Stimulants must be freely given internally, 
quinine, camphor, capsicum, &c. The quinine must be given in 
large doses, (grs. v. to x.,) at short intervals ; it should be combined 
with capsicum or camphor, or if there is severe vomiting, the oil of 
turpentine may be substituted for the camphor. The evidence in 
favour of large doses of quinine repeatedly given in congestive 
fever, is ample and convincing. Calomel is generally combined 
with the above remedies, and is administered during the paroxysm, 
to the amount of fifteen or twenty grains.] 



448 



CHAPTER VIII. 



INFANTILE GASTRIC REMITTENT FEVER. 

[Syn.— Remittent Fever of Children, Spurious Worm Fever; Febris verminosa, Hectica 
Infant alls, Febris Mucosa verminosa, #c] 

Many of the names by which this disorder of children has been 
at various times known, have been applied either from some sup- 
posed cause of the symptoms, or from some prominent character- 
istic of the disease itself. Thus it has been called the ivorm fever 
— the mesenteric fever — the stomach fever — the low fever of chil- 
dren — infantile hectic — the infantile remittent fever. On a care- 
ful examination of the history and symptoms, as given by various 
authors of former and recent times, we are satisfied that much con- 
fusion has arisen, sometimes from imperfect attempts to separate 
into distinct diseases what are in fact but early and later stages of 
the same, and on the other hand, from an opposite error of con- 
founding what are accidental complications, with what may be 
considered as the regular and simple form of the complaint. 
There is apparently a striking conformation of the modern doctrines 
of Broussais as to the nature of fever, in the acknowledged cause 
of this infantile disease. The most prominent symptoms are re- 
ferred to the mucous lining of the stomach and intestines; an 
acute or a protracted form of fever is the result ; and with an im- 
proved condition of the alimentary canal the febrile paroxysms 
are mitigated and gradually disappear. In the various forms of 
continued fever there is so much diversity in the complications of 
local lesions, as well as in different seasons, and in different epide- 
mics, as materially to detract from the soundness of, if not to dis- 
prove, the doctrines of this celebrated pathologist. In the fever 
under consideration, however, no such diversity exists. The 
description given by the first distinct writer on the subject, Dr. 
Butter, of Derby, in 1782, agrees in all essential points with that 
published twenty-four years afterwards by Dr. Pemberton, the 
accuracy of which is admitted by the most recent writers and 
practitioners. Dr. Butter, in his work on Infantile Remittent 
Fever, has divided the disease into the acute, the .s/oz#,and the low 
form. Dr. Underwood, who published the first edition of his 
work on Diseases of Children, two years after Dr. Butter's trea- 
tise appeared, gives the name of infantile remittent only to the 
very mildest form of the complaint, and devotes but a very short 
chapter to what he considers a fever, "remarkable for being 



SYMPTOMS. . 449 

always devoid of danger." In alluding to Dr. Butter's recently- 
published work, he clearly considers that he has exaggerated the 
importance and severity of the disease. But Underwood proceeds 
to describe in subsequent chapters, the typhus or low fever, and 
the hectic, which are evidently identical with the low and the slow 
forms of Butter. 

For practical purposes we are of opinion that the division into 
the acute and the chronic will be sufficient ; and that in describ- 
ing these two forms there will be ample opportunity to notice all 
the necessary details, whilst the arrangement will be much sim- 
plified. 



I. ACUTE INFANTILE REMITTENT FEVER. 
I. SYMPTOMS. 

It is not in earliest infancy that this disease is most commonly 
met with — indeed, many have denied its existence in children dur- 
ing the period of lactation. It is most frequent from the age of 
two to six ; but preserves its peculiar character up to the age of 
puberty, though, the older the child grows, the less marked are 
those peculiarities of type. In the acute form, the symptoms often 
come on very suddenly. The child perhaps goes to bed apparently 
as well as usual, and in an hour is found with a burning skin, a 
flushed countenance, an injected eye, and a very rapid pulse, vary- 
ing perhaps from 120 to 160. There is intense thirst, with a dry 
tongue, which soon becomes coated and covered with a thick white 
fur ; the child is restless and wide awake, often delirious, but able 
to answer questions or do as directed. If old enough, the child 
often complains of pain in the head and sometimes in the abdomen, 
the parietes of which are generally more hot than any other part 
of the body ; indeed, the feet are often cool or cold. There are occa- 
sionally sickness, and vomiting of sour and offensive, or of greenish 
or yellow fluid. If the proper remedies be used, in a few hours the 
skin becomes cool, perspiration breaks out, the tongue is found to 
be moist, the pulse softer and more quiet; the child falls into a deep 
and refreshing sleep, and on awaking appears nearly as well as the 
day before. 

When the attack originates in a single meal of improper or un- 
digested food, which has been dislodged by the appropriate treat- 
ment, such a speedy and favourable termination of the symptoms 
is not unusual. The name of remittent fever, which is so gene- 
rally applied to the confirmed disease, would in such a case be in- 
appropriate ; but such is the history of the disease in its first stage 
and most simple form. It is rare, however, to find the cause so 
limited, and then the history is somewhat different ; where, instead 
of a single error of diet, there has been previously an accumulation 
29 



450 GASTRIC REMITTENT FEVER. 

of ill-digested or of improper articles of food in the alimentary 
canal, although the attack may beg4n as suddenly, the termination 
is not so abrupt or satisfactory. Instead of the child being free 
from fever in a few hours after the onset of the paroxysm, there is 
only a remission of the symptoms ; there are languor and fretfulness 
in the morning; the tongue is moist, but continues coated; the 
skin is cool, but dry ; the pulse is quicker than natural, but not so 
rapid as during the accession of the symptoms ; there is often drow- 
siness, and generally loss of appetite ; the urine is scanty and high- 
coloured, and often deposits a white sediment. These remaining 
symptoms may be present more or less for several hours, though 
occasionally the child seems lively, takes notice of, and interest in 
its usual pursuits, and is apparently nearly well. Towards even- 
ing, however, it becomes more restless and uncomfortable, and a 
distinct exacerbation of febrile paroxysm, often more intense than 
that at the onset of the disease, takes place, running the same 
course, and followed in the space of a few hours by as remark- 
able a remission. The condition of the bowels is one of the most 
uniform characteristics of the disease. Sometimes there is 
diarrhoea, much more commonly, however, constipation ; but in 
either case the evacuations are highly offensive, the fetor resem- 
bling putrid meat. They are dark, pitchy, or clay-coloured, with 
little or no admixture of bile, or the biliary secretions appear 
vitiated and unmixed with the general mass. When the bowels 
have been previously confined, the accumulation of morbid secre- 
tions is usually enormous, and dose after dose of active purgatives 
is necessary to dislodge the offensive load. After the bowels have 
been cleared out, the dejections are still highly fetid, dark, and 
slimy, and their character is found to improve with the subsidence 
of the febrile accessions. In the course of the disease the breath 
early shows a faint and often an offensive colour, the coat on 
the tongue becomes more yellow or dirty, and the child is noticed 
to be frequently picking its lips, its nose, the corner of its eyes 
or its fingers. There is also not uncommonly a short hacking- 
cough. As convalescence approaches, the paroxysms of fever be- 
come less marked, take place at a later hour, and last a much 
shorter time. The intervals of remission are longer, and are in- 
deed almost complete intermissions, the child becoming more lively, 
returning to its natural habits, and recovering its appetite and 
strength. In other instances the disease does not come on so sud- 
denly. For a few days the child is heavy and fretful, with dis- 
turbed sleep, loss of appetite, and coated tongue; the febrile accessions 
are very slight and irregular^but go on increasing in length and 
severity, till the more decided symptoms appear, and run a similar 
course. 

The dilation of an attack of the acute form varies from a few 
hours to a week or a fortnight, after which it gradually assumes a 



SYMPTOMS. 451 

chronic form, and is often very protracted. The improvement in 
the condition of the alvine discharges is one of the earliest signs of 
recovery ; they become less and less fetid, and more natural in 
appearance, and when the free and healthy action of the liver first 
begins, bright orange-colonred bile is frequently poured ont in great 
profusion. The dejections are more decidedly feculent, and, if the 
food be of a proper quality, they are properly smooth and blended; 
the urine becomes more abundant, pale, and without lateritious 
deposit; the tongue becomes gradually clean ; the disposition to 
pick the skin ceases ; the sleep is tranquil and refreshing ; the coun- 
tenance is no longer subject to irregular flushings, or to the peculiar 
pallor during the remissions ; the skin is soft, moist, and cool ; the 
pulse tranquil; and convalescence is established. For a considerable 
time after this favourable termination, however, a slight error in 
diet, either as to quality or in quantity, will bring on a relapse. 
The same effect will often result from omitting to keep the bowels 
free from any accumulation, from the too early use of tonics, from 
exposure to damp air, cold, or mental or bodily exertion. Fre- 
quent relapses generally terminate in the chronic form, and it is 
important to bear in mind, that a frequent cause of relapse, as 
well as of some of the complications to be presently mentioned, is 
not unfrequently to be traced to the too long continuance of vio- 
lent purgatives, or to the irritating nature of the remedies em- 
ployed. 

Without subscribing to the doctrine of Underwood, that this 
disease is " remarkable for being always void of danger," it is cer- 
tainly true with respect to the simple acute form: we have never, 
indeed, met with or heard of a case terminating fatally ; where 
death has occurred, the case has been at an early period compli- 
cated either with dysentery, or gastric or enteritic inflammation. 
In such instances the symptoms have been mixed, and the fever 
has soon lost much of its remittent character, though in all infan- 
tile complaints there is a great tendency to remissions, which ob- 
serve a marked degree of regularity. The dysenteric complica- 
tion is indicated by the appearance of the evacuations, which are 
frequent, attended with violent straining, consist almost entirely of 
mucus, and are often mixed with blood ; while the acute pain in 
some part of the abdomen, increased on pressure, with retraction 
of the limbs, early tympanitis, and tendency to constant sickness, 
indicate the existence of intestinal inflammation. In the acute 
stage of these complications, the peculiar fetor of the evacuations 
soon ceases to be constant, and often entirely disappears ; but it 
returns again after a time, perhaps, notwithstanding that the in- 
flammatory state of the intestinal mucous membrane has sub- 
sided. By the majority of practitioners in this country, however, 
this absence of fetor of the stools, in the progress of the acute form 
of infantile remittent fever, is not considered to be at all uncom- 
mon; and they are unwilling to admit the existence of infiamma- 



452 GASTRIC REMITTENT FEVER. 

tion in such cases. The presence of pain, on the other hand, is 
by no means a necessary proof of the existence of inflammation, 
and the tenderness on pressure is often deceptive, as young chil- 
dren, in the fretfulness of disease, are exceedingly impatient of 
any sort of disturbance, and evince great dislike to pressure on 
the abdomen or any part of the surface. We must not lose 
sight also of the fact stated by Andral and others, that even the 
most severe and fatal forms of intestinal inflammations are often 
painless. 

We have stated our belief, that when death takes place in the 
acute form of infantile remittent fever, the disease is complicated 
either with dysentery, or with inflammation of the mucous mem- 
brane of some portion of the alimentary canal. The appearances 
on dissection confirm this view; patches of the mucous membrane, 
generally of the small intestine, being softened, sometimes abraded, 
or inflammatory blushes and circles surrounding the mucous folli- 
cles. In some cases a pink blush pervades a considerable portion 
of the tube. In the instances where dysenteric symptoms have 
been most prominent, ulcerations in the ileum, caecum, colon, or 
rectum, have been discovered. 



II. CAUSES. 

The causes of the acute form of the infantile fever are those 
which directly or indirectly disorder the digestive organs. When 
a child has been previously in perfect health, the bowels regular and 
natural in their functions, and the diet wholesome, the onset of the 
symptoms may be generally traced to some accidental deviation 
from ordinary diet. Although disorders of the stomach and bowels 
in children are said to be most common in the summer and autumn, 
from the temptations to indulge in fruit, ripe, or unripe, in our ex- 
perience the acute form of gastric remittent is more prevalent about 
the period of Christmas, when the rich and indigestible fare of this 
season is partaken to excess by children who are too often encour- 
aged by the foolishness of friends. The same symptoms again often 
arise when there has been no error in diet, but where digestion has 
been suddenly checked by exposure to cold or wet, or by some vio- 
lent exercise or passion of the mind, soon after a hearty meal. The 
attack in these latter cases is even more sudden than in the former, 
for even where the illness may clearly be traced to so,me gross error 
of diet, the symptoms of fever often come on more slowly. In the 
instances in which the fever runs the shortest course, and the 
symptoms are subdued, and the child restored to health in a few 
hours, the stomach alone seems to be affected. In the more pro- 
tracted forms, the intestinal canal through its whole extent is 
more or less involved. In the complicated cases the irritation of 
the surface proceeds a stage farther, and there is ample reason 



DIAGNOSIS. 453 

to conclude that gastric inflammation has been excited. Whe- 
ther this is a superadded affection, often the result of improper 
treatment, or merely an advanced stage of one and the same dis- 
ease, is a question about which there will probably be a diversity 
of opinion. 



III. DIAGNOSIS. 

We have observed that gastric remittent fever in its simple form 
becomes dangerous, rather from the complications with which it 
occasionally becomes involved during its progress, than from the 
actual severity of the disease itself. Whilst it is important to recog- 
nize such complications in their earliest onset, we must not forget 
that it is equally important not to confound the primary and secon- 
dary diseases, and that there are some affections which, though some- 
times co-existent, are often through mistake considered as the pri- 
mary or sole existing disease. 

The presence of worms in the intestines produces some symptoms 
which to a certain degree resemble those of the remittent fever. At 
one time the complaint was generally supposed to depend upon this 
cause entirely ; hence the appellation worin fever. Dr. Butter ex- 
posed the fallacy of this theory, and went so far as to declare, that 
so far from worms producing this fever, or many of the other serious 
maladies which have been ascribed to their irritation, their presence 
in the intestines was at least harmless and probably salutary, pro- 
ducing by their irritation an increased peristaltic action, by which 
the offensive matter which formed their pabulum was more ex- 
peditiously removed. Without going so far, we agree with Dr. 
Butter, that the mischief from worms in children has been consi- 
derably overrated, and that much harm has sometimes arisen from 
the use of, and perseverance in, the more violent anthelmintics. 
Picking of the nose and lips, wasting of the flesh, pale countenance, 
enlarged abdomen, irregular appetite, coated tongue, with fetid 
breath, and unhealthy, dark, and slimy evacuations, would lead a 
practitioner, and even an unlearned nurse, to suspect the presence 
of worms. In these we recognize many of the symptoms of the 
infantile remittent fever ; but there is no fever, especially with re- 
missions, accompanying the presence of worms. There are also 
other points of distinction in vermination, such as itching of the 
anus, occasional voracious appetite, grinding of the teeth, and gnaw- 
ing pain in the stomach. Neither is the emaciation so rapid or so 
great ; and though there may be now and then flushing of the face, 
the flush is partial, and often confined to one cheek: the peculiar 
condition of the urine before noticed is also absent in simple cases 
of worms. 

The frequent hacking cough, with fever in some respects resem- 
bling hectic, might lead to a difficulty in distinguishing gastric fever. 



454 GASTRIC REMITTENT FEVER. 

The occasional existence of tubercles in the lungs, in every stage of 
disorganization in young children, and even in the unborn foetus, 
though more rare than in adults, has been most clearly proved: 
when there is superadded to the remitting fever of the real hectic 
the peculiar picking propensity, many might be led to fix upon the 
bowels as the sole source of irritation ; but we have often seen cases 
where, though the picking was strongly marked, there was no in- 
testinal irritation, the lungs being the seat of extensive disease. In 
the protracted forms of remittent fever, especially in scrofulous con- 
stitutions, tubercles in the lungs are very apt to form or be called 
into action, and lead to a fatal termination. It is of course highly 
expedient to recognize their presence and the progress of disorgani- 
zation ; in modern times mistakes are less likely to occur, if auscul- 
tation be resorted to in doubtful cases. Besides this, the presence 
or the absence of the depraved and fetid evacuations from the 
bowels, the enlarged abdomen, the coated tongue, and other signs 
of intestinal disorder, will guide our opinion ; but it is on the signs 
conveyed by percussion and auscultation that we can best depend 
for an accurate diagnosis. 

Tabes mesenterica, which forms one of the most common com- 
plications, and is often produced by the irritation in the mucous 
membrane of the bowels, which takes place either in the course of 
the disease, or as the result of improper treatment, is also more fre- 
quently confounded with the chronic form of gastric fever than per- 
haps any other malady. The features of resemblance are, however, 
sufficiently distinct to enable us to distinguish between them ; but 
we must not fail to remember that the two diseases often run their 
course together, especially in children of the scrofulous diathesis. 
Of course when this occurs, the concurrence of the blended symp- 
toms will give us a correct view of the case. In mesenteric disease 
we find wasting, " but it is slow and regular, not variable and rapid 
as in bowel-complaints." (Evanson and Maunsell on the Diseases 
of Children, p. 294.) The appetite is voracious, the abdomen en- 
larged and hard, and in the advanced stages enlarged veins may be 
seen meandering over the surface. The enlarged glands of the 
mesentery may be generally distinguished by manual examination 
of the umbilical region, and it is rare to find instances where other 
glandular enlargements, chiefly in the groins and the neck, do not 
take place at the same time. To these signs we may add the occa- 
sionally griping pain about the navel, increased by deep pressure, 
with the regular recurrence of dull pain in the abdomen, lasting 
often for three or four hours, and accompanied with a sensation of 
sickness on pressure. There is generally a permanent rapidity of 
the pulse and hectic exacerbations, but no regular remitting parox- 
ysms, and no picking. The appearance of the dejections is also 
peculiar, differing from those in the remittent fever in many remark- 
able points. The motions in mesenteric disease are white and 
chalky, or dark and ochry, or even blue or gray, but rarely fetid or 



TREATMENT. 455 

slimy, and not tinged with either yellow or green bilious matter. 
They generally appear altered by the omission of some of the usual 
ingredients of healthy feces, and not by the excess or addition of 
depraved matters. 

Most authors have particularly dwelt on the diagnosis between 
hydrocephalus and gastric remittent fever, and certainly it is of 
great consequence that no mistake should arise in confounding the 
one with the other, as it might lead to a fatal error in the treatment. 
In the acute forms of either complaint the mistake would be very 
unlikely to take place, and, therefore, the question of their diagnosis 
need not occupy our attention. In chronic remittent fever, the child 
is so often reduced to an excessive state of exhaustion and emacia- 
tion by what is called bold treatment, that it is-not uncommon to 
meet with the train of symptoms resembling the hydrencephaloid 
affection described by Drs. Gooch and Marshall Hall ; and as 
the size of the head remains stationary, whilst the neck, body, and 
limbs waste, the deceptive appearance of enlargement of the head 
is often given. In scrofulous constitutions we may often meet with 
real cerebral disease, especially of that form called tubercular 
meningitis, where tubercles are developed in the substance of the 
brain itself, during the protracted course of remittent fever. When 
we consider also how constantly disordered states of the digestive 
organs produce functional disturbance of the brain, it will be easy 
to suppose that disease of structure would be likely to follow. We 
here meet with the chief difficulties, because, whilst the occurrence 
of cerebral symptoms is to be watched for, guarded against, and 
properly treated, we must not neglect the condition of the digestive 
organs as the original seat of the mischief, and the cause perhaps 
of the complications. The drowsiness and stupor which are some- 
times found accompanying simple remittent fever, both during the 
paroxysm and in the stage of remission, are different from similar 
symptoms arising in cerebral disease, as there is always a readiness 
to be roused, no affection of the pupil, and no strabismus. The 
head also is not, whilst the abdomen is, the hottest part of the body, 
and there is no convexity of the fontanel le, distension of the veins 
of the scalp, or peculiar expression of countenance, which denote 
the chronic forms of affection of the brain and its membranes. When 
we take into consideration also the absence of convulsions, of obsti- 
nate constipation, suppression of the urine, and the other more 
decisive proofs of effusion, and moreover, reflect on the symptoms 
which characterize the true gastric remittent fever, the two diseases 
can scarcely be confounded. 



IV. TREATMENT. 

Keeping in view the usual exciting causes, if we are called to 
the patient sufficiently early, and especially if there be sickness, an 



456 GASTRIC REMITTENT FEVER. 

emetic of ipecacuanha will be advisable, the action of which may 
be encouraged by warm diluent drinks. This will sometimes dis- 
lodge the offending mass, at once relieve the symptoms, and the 
child will fall into a placid sleep ; the next morning, however well 
the child may appear, it will always be proper to administer an 
active purgative, either of calomel with jalap or scammony, or a 
dose of castor oil, salts and senna, or rhubarb and magnesia, pro- 
portioning the dose to the age of the child. Should the time for an 
emetic have gone by, from the number of hours which have passed 
before our assistance is required, we may begin at once with the 
purgatives, but then it will be generally found necessary to give the 
calomel alone in the first instance, on account of the irritability of 
the stomach rendering it difficult for the child to retain medicines 
which are nauseous or in large quantity, but following it up a few 
hours after with some other purgative. Enemata may be conveni- 
ently employed should this irritability of the stomach, or the obsti- 
nacy of a young child, interfere with the administration of ordinary 
purgatives. A warm bath should also be used, particularly if there 
be much restlessness, or, should this be inconvenient, the feet and 
the abdomen may be fomented. Effervescing saline draughts, or 
a few grains of nitrate of potass in solution, or some of the nearly 
tasteless neutral salts, such as the tartrate or phosphate of soda, may 
be given at intervals in lemonade or barley-water. The room 
should be kept perfectly cool and still, the light should be excluded, 
and the patient supplied frequently with cooling drinks. The re- 
moval of the contents of the alimentary canal is generally followed 
by a subsidence of the febrile paroxysm; as long, however, as the 
stools are fetid and unhealthy, the patient will be liable to a recur- 
rence of the fever, and the abatement of the symptoms will not be 
complete. If the last evacuation appear healthy, with due admix- 
ture of bile, we may leave the patient at rest for a time. In the 
interval great care must be taken that the nourishment given be 
entirely fluid, and of such quality as to be unirritating and easily 
assimilated ; barley or grit, gruel, weak broth, arrow-root, or rennet 
whey, will be the safest articles of food. If the dejections continue 
healthy, there will probably be little or no return of fever, and it 
will be only necessary to take care that the child resume its usual 
habits and its ordinary diet with the greatest caution. Should, 
however, the regular remissions of fever supervene, it will be requi- 
site, on the recurrence of the paroxysm, to resume the treatment. 
It is not uncommon to find the bowels exceedingly obstinate, so 
that very large doses, or a frequent repetition of purgatives, is 
required to expel the acrid ingesta. 

It is always necessary to inspect the evacuations, instead of 
trusting to the report of the nurse. The state of the abdomen on 
pressure, as to fullness and hardness, must be also attended to, and 
we should closely watch the indications of pain or tenderness. The 
fullness and hardness, distinct from collections of air, which are 



SYMPTOMS. 457 

easily detected by percussion, will denote the necessity of follow- 
ing up the use of active purgatives, which may be continued at 
sufficient intervals, so as not to harass and exhaust the patient, 
till we are satisfied that the intestines are emptied. The signs of 
tenderness on pressure should lead us to be very cautious in the 
exhibition of irritating purgatives ; castor oil or the neutral salts 
will perhaps be the safest, and the calomel may be combined with 
extract of henbane or hemlock, and given in smaller doses at 
shorter intervals. The abdomen should now be fomented, and if 
the pain increases and becomes constant, and the febrile symp- 
toms more permanent, there will be no doubt as to the propriety 
of applying leeches, which we have found more salutary than 
general blood-letting. The number of leeches, and the repetition 
of them, must of course be adapted to the strength and age of 
the child, as well as to the severity of the symptoms. Many have 
urged that the disease is so exhausting and so liable to be pro- 
tracted, that abstraction of blood should be avoided ; but it will 
generally be found that active treatment, pursued judiciously in 
the early and acute form, will be most likely speedily to arrest the 
symptoms, and prevent the exhaustion consequent upon the more 
protracted or chronic form. As the symptoms subside, smaller 
doses of the remedies recommended may be employed ; at more 
distant intervals, and when the secretions have become healthy, 
the tongue clean, and the fever subsides, it will be sufficient to 
give a gentle dose of rhubarb with magnesia or sulphate of potass 
every other day. At this time the power of the digestion may 
be assisted by a light vegetable bitter, with ammonia or the other 
alkalies, twice or three times a day ; and we have much confi- 
dence in the mineral acids, and especially in Meynsicht's vitriolic 
elixir (an imperfect ether, formerly much in repute in atrophy 
and consumption), in doses of from five to thirty drops, accord- 
ing to the age of the child. As the appetite returns, the diet may 
be slowly and cautiously improved ; but it must be always re- 
collected that the slightest excess or carelessness, or any neglect in 
the management of the bowels, will be likely to be followed by a 
relapse. 



II. CHRONIC INFANTILE REMITTENT FEVER. 
I. SYMPTOMS. 

The chronic form of infantile remittent fever either succeeds to 
an acute attack, or begins in a more slow and insidious manner, 
after a longer continuance, or a succession of causes similar to 
those which induce the acute form. Long habits of indulging in 
improper articles of diet, swallowing food rapidly, and conse- 
quently without due mastication, carelessness and neglect in the 



458 GASTRIC REMITTENT FEVER. 

management of the bowels, and perhaps exposure to an impure, 
damp, or cold atmosphere, and insufficient exercise, are the most 
frequent causes of this form of gastric remittent fever. Dr. But- 
ter {op. cit., p. 33) is of opinion that both forms of the disease 
are occasionally epidemic and even contagious : there are certain 
seasons, as before mentioned, at which it is more prevalent, from 
circumstances incidental to the period of the year, rather than from 
any state of the atmosphere ; we have never met with instances 
where it could fairly be considered contagious, and we believe 
that this doctrine is now exploded. This form of gastric fever is 
frequently observed to follow many of the ailments to which 
early childhood is liable, such as hooping-cough, measles, scarlet 
fever, or accidental attacks of diarrhoea from dentition, &c, chiefly 
perhaps, because in the course of such diseases, the digestive func- 
tions are often much deranged, and in the anxiety to restore 
strength, nourishing diet is too early and too abundantly supplied. 
The symptoms resemble those of the acute variety, except in 
intensity ; some are less severe, others more marked. The pa- 
roxysms of fever are less intense, but they last longer, and in the 
intervals the child is less free from irritation : there is not, perhaps, 
so large a collection of solid fecal matter in the intestines, and the 
offensive smell is less striking, the dejections having rather a faint 
odour ; but there is often diarrhoea, and the colour of the motions, 
whether spontaneous or resulting from medicine, is as unhealthy, 
often very dark or clay-coloured, or resembling thin mud. The 
abdomen is hot and tumid from flatulence, the tongue loaded with 
a dirty fur, the edges often red and dry, but becoming more moist, 
though not cleaner in the remission ; the teeth are often covered 
with sordes, and the lips parched ; the skin feels harsh, and from 
the rapid wasting hangs in wrinkles about the limbs : in very pro- 
tracted cases the child has the appearance of shriveled old age. 
The urine is scanty and high-coloured, with much white sediment, 
especially during the remissions ; the breath is either very offensive 
or has a peculiar faint odour ; there is generally also frequent hack- 
ing cough, and in a remarkable degree the propensity to picking 
before mentioned, not however confined to the lips, eyelids, nose 
or fingers, but the child picks every part of the body, the bed- 
clothes, and even the face of the nurse. If there be an accidental 
pimple on the skin, that will usually become the favourite spot to 
be picked, and sores are often produced, the edges of which are still 
more eagerly attacked, so that the fingers are constantly strained 
with blood. This picking is by many considered one of the most 
conclusive signs of the genuine disease ; we have, however, met 
with two cases, in which it was a very prominent symptom, 
though the patients had no particularly disordered condition of 
the digestive organs, but died from empyema supervening or follow- 
ing hooping-cough complicated with pneumonia. As this picking 
becomes so intense, in what Dr. Underwood by his description 



TREATMENT. 459 

considers the infantile hectic fever '(which is only the advanced 
stage of the chronic remittent), perhaps it may be ranked as a 
symptom belonging to the hectic of children, whether produced by 
intestinal or pulmonic or other organic disease. In the advanced 
stages the fretfulness of the child is often most distressing, or some- 
times it lies for hours taking little or no notice of anything, and 
either apparently dozing with half-closed eyes, or when roused im- 
mediately resuming the incessant picking. At this period the appe- 
tite is very often craving, and the child evinces great irritation and 
distress on being denied food. In other cases there is urgent thirst, 
but the appetite is lost ; in others again there is neither appetite nor 
thirst, so that there is great difficulty in getting the child to swallow 
anything, from its dislike to be disturbed. In the still more severe 
cases there is generally some complication, either diarrhoea or dysen- 
tery, when the mucous lining of some portion of the intestines is 
found either softened, abraded, or the intestinal follicles enlarged 
and in various stages of ulceration. It is still more common to 
find that mesenteric disease is excited by the extension of the 
irritation to those glands ; when this happens the abdomen is 
hard and tumid, and the enlarged glands may often be felt through 
the parietes of the abdomen. This complication is more apt to 
occur where there is a scrofulous taint, and in such constitutions 
tubercular disease in the lungs occasionally supervenes. Instances 
of death without one or other of these complications are rare; 
and even when the child appears to be reduced to the lowest de- 
gree of emaciation and debility, by proper treatment recovery may 
be effected. 



II. TREATMENT. 

The remedies for the chronic form of gastric remittent fever are 
to a certain extent necessarily similar to those which have been 
recommended in the acute. It is not an uncommon mistake, how- 
ever, to employ too active measures, and especially to administer, 
almost daily throughout this more protracted disease, acrid purga- 
tives, and even large doses of calomel, by which not only the irri- 
tation of the mucous membrane is aggravated to a fearful extent, 
but the more fatal complications already enumerated are frequently 
induced. It is not at all unusual to meet with instances where 
purging is pushed so far, that a fatal dysentery is the consequence, 
characterized by dejections of bloody mucus, or of fibrin assuming 
the tubular mould of the intestines. In other cases the inflamma- 
tion terminates in softening, abrasion, or ulceration of the mucous 
membrane, and there is also reason to suppose that mesenteric 
disease has been excited or accelerated by this abuse of purgatives. 
One would suppose, by the directions often given by practitioners, 
that it was impossible to purge or starve too much in these cases ; 



460 GASTRIC REMITTENT FEVER. 

bat it is chiefly under such, treatment that we meet with those 
examples of extreme emaciation and lingering disease, in which the 
constitutional powers are either destroyed, or death ensues. 

If, in the first instance, we have reason to suspect accumulation 
in the intestines, an active purgative, containing calomel, may be 
safely and advantageously administered; nor is there any objection 
to have such more powerful medicine occasionally repeated, espe- 
cially if, by any error of diet or negligence in the management, a 
relapse or an increase of the symptoms has taken place. But after 
the purgatives have sufficiently cleared the bowels, the secretions 
will be best improved by milder remedies: mercurials in gentle 
doses, especially the hydrargyrum cum creta, or calomel rubbed 
down with chalk, should be given every night, or every other night. 
A combination of the mercurial with a diaphoretic, particularly 
ipecacuanha, or, if much restlessness, with Dover's powder, will be 
found very useful. A mild purgative on the following morning, 
such as castor oil, compound decoction of aloes, rhubarb and mag- 
nesia, or rhubarb with sulphate of potass, will be necessary. Den- 
man, Underwood, Butter, and Pemberton have all spoken highly 
of this latter preparation, considering it peculiarly adapted to meet 
the indication, by relieving the fever, improving the secretions, and 
quickening the action of the bowels and kidneys. The quantities 
must, of course, be adapted to the age and strength of the patient, 
but from two to three evacuations will be desirable daily ; a larger 
number will exhaust the child, and fewer will scarcely keep the 
bowels sufficiently free from offending matters. Saline medicines 
at intervals will be also beneficial ; and the addition of henbane, 
hemlock or lettuce has been found, by most practitioners, to allay 
the general irritation, compose the restless distress of the child, and 
render the action of the remedies more genial. Frictions with oil 
over the abdomen, or of slightly stimulating lotions, will often be of 
use, and we have especially observed advantage from the nitro- 
muriatic acid largely diluted. A nightly warm bath should not be 
omitted; it promotes perspiration and relieves the mucous surface, 
besides composing the child and contributing to its comfort. 

The diet during the early treatment should be such as will most 
easily assimilate, and will be least likely to produce irritation, if 
only partially digested; for this purpose we may allow chiefly bar- 
ley-water, rennet whey, thin arrow-root, or other farinaceous 
gruels, and weak chicken or veal broth. When there is thirst, 
soda-water, or toast and water, or slightly acidulated beverages may 
be taken. 

It is not only that the secretions are unhealthy, but the digestive 
functions seem entirely suspended in this disease ; so that, as Dr. 
Pemberton has remarked, the food is often passed through the 
bowels, either unchanged or converted into a putrid mass, as if it 
had been merely subjected to heat and moisture, and not to diges- 
tion. On this account, as soon as the febrile symptoms have sub- 



TREATMENT. 461 

sided, the tongue has begun to clear, and some portion of healthy 
bilious or feculent matter passed from the bowels, we may com- 
mence very cautiously the use of such means as will gradually re- 
store the tone of the stomach and bowels, as well as improve and 
remove the unhealthy secretions. 

In the more early stages of improvement, we have found the 
mineral acids, upon the whole, the safest medicines for this purpose. 
The infusion of roses may be conveniently employed, and it will be 
easy to add some of the neutral salts, with which sulphuric acid is 
not incompatible, to answer the other indications required. Nitric 
acid, or chlorine, by acting perhaps upon the liver more than the 
other acids, may be in some respects preferable. Meynsicht's 
vitriolic elixir has also with much justice been praised. The vege- 
table bitters combined with rhubarb or aloes, and some alkali, may 
in some cases be given at an early period ; but great caution must 
be used, as a too early recourse to tonics may renew the accessions 
of fever, with the whole train of disordered actions. As conva- 
lescence advances, more decided tonics may be tried, such as bark, 
quinine, or the preparations of iron ; but it will still be advisable 
to give occasional doses of aperients, and perhaps also of mercu- 
rials. 

The gradual improvement of the diet may keep pace with the 
trial of the tonics and the renovated power of the stomach; but ex- 
treme caution is necessary in this respect, both as to the quality and. 
quantity of the food. A larger meal than usual, even of the safest 
description, is often followed by a serious relapse ; while premature 
indulgence in more solid diet, or the least carelessness as to the indi- 
gestible nature of it, will at once undo all that has been effected 
towards recovery. For many weeks after convalescence has appa- 
rently been established, this cautious restriction is advisable ; and 
the injudicious pampering by parents and friends, under the pretext 
of strengthening the poor debilitated child, becomes one of the most 
frequent causes of ultimate disease. In the stage of convalescence 
the skin should be guarded from damp and chills, a very ready 
source of derangement of the digestive organs, whilst pure air, 
well-ventilated apartments and tepid bathing are valuable auxilia- 
ries. The advantage of change of air is great. Dr. Evanson in- 
deed remarks that, " through the whole management of remittent 
fever, nothing is more remarkable than the benefit derived from the 
latter source (change of air): we have frequently seen a patient 
who had been several weeks labouring under the disease, enjoy 
tranquil and refreshing sleep the night after his removal to a dis- 
tance of three or four miles from his ordinary abode." 



462 



CHAPTER IX. 



HECTIC FEVER. 



£Syn. 'ektijch ; Febris hectica, F. Amatoria, F. lenta, F. Ampherina hectica, Atrophia, 
JEpanetus hectica; Fievre hectique, Fievre lente, Fr. ; Etica Febbre, Ital.; Das Schleich- 
endes Fieber, Hektiches Fieber, Germ.] 

Hectic Fever, so named on account of its'continuity and invete- 
racy, (from the Greek adjective, ixiixbs, habitual,) has been arranged 
by not a few pathologists among Primary Fevers. The soundness 
of that arrangement, however, will scarcely be admitted in the pre- 
sent day ; for it seems well-established, that true hectic occurs only 
in connection with serious organic alterations of structure, and 
seldom unless where suppuration exists. It is onJy by extending 
inconveniently the meaning of the term hectic, this affection can be 
viewed as primary in its nature. 

As generally understood by British practitioners, it may be de- 
fined — A form of remittent fever of long and indefinite duration, 
consisting of an exacerbation once or sometimes twice a day, 
attended ivith extreme attenuation of the body, and depending 
either on suppuration or upon important organic derangements 
of structure. Some modern authors, and among these M. Brous- 
sais, the latest writer who has written expressly on the subject, 
have adopted a much more comprehensive definition, according to 
which " hectic consists of a slow continued fever of long and inde- 
finite duration, and attended with debility and emaciation." This 
definition has been adopted, as appears from the writings of the 
last-mentioned author, in order to include what has been more 
recently characterized, especially in this country, under the name 
of irritative fever, and which it is important to distinguish from the 
true hectic of existing nosologists. 



I. SYMPTOMS. 

The symptoms of hectic fever, when it is fully formed, are very 
characteristic. Like other fevers it is obscure in the beginning, and 
can scarcely be distinguished from the febrile state at the com- 
mencement of continued fever, or that which attends some chronic 
internal inflammations, chronic visceral derangements of structure, 
and gastro-intestinal irritation. The pulse is generally frequent, 
varying between 90 and 120— always irritable, so that slight sources 



SYMPTOMS. 463 

of excitement increase its frequency — and usually small, jarring, 
yet compressible. Irregular exacerbations occur, preceded fre- 
quently by chilliness, attended with heat of skin, some flushing of 
the features, and a burning sensation in the palms and feet, but not 
always followed by perspiration. Although the exacerbations 
occur irregularly upon the whole, they are observed to be most 
frequent after meals, especially breakfast, and to recur very regu- 
larly in the fore part of the night, at which time the paroxysm is 
generally greater than at any other period. The digestive functions 
are at this stage not unfrequently, yet by no means invariably dis- 
turbed, the tongue being loaded, the stomach weak and the bowels 
subject to constipation. There is always much debility ; and the 
emaciation is commonly great in proportion to the amount of fever 
and other functional disturbances — -although some remarkable ex- 
ceptions are observed to this rule, even in that most unequivocal of 
all forms of hectic which attends pulmonary consumption. 

The disease continuing to advance along with the progress made 
by its fundamental cause, its characters gradually become more 
strongly marked and diagnostic. The irregular febrile paroxysms 
gradually pass into a continual state of excitement of the pulse, 
with a regular exacerbation of fever occurring at least once and 
often twice in the twenty-four hours, usually at the same periods 
of the day. The principal exacerbation commonly begins towards 
evening, reaches its height about midnight or a little later, and goes 
off early in the morning. Cullen held that another exacerbation 
in the forenoon was an essential character of hectic fever. This, 
however, is a mistake, into which he was led probably by his erro- 
neous physiological belief in a double diurnal revolution in the rate 
and excitability of the circulation in the healthy state of the body. 
There is no doubt that a secondary exacerbation often takes place 
during the forenoon in hectic fever. But in very many cases no 
such incident is observable ; and in many others where it does 
seem to occur, the exacerbation is not essential, but incidental 
merely, and nothing else than an increase of that diurnal febricula 
or excitement, which takes place in many irritable habits in con- 
sequence of the digestion of the meal of breakfast.* In some 

* The doctrine of Cullen- and other physiologists, that the healthy circulation 
is subject to a double diurnal excitement, and that the chief period of excitement 
occurs in the evening, was first disproved by Dr. Knox in 1816. He found that 
there is only one diurnal revolution, independently of incidental excitements; 
that the pulse is more frequent and excitable in the morning on awaking, gradu- 
ally becomes less so towards evening, and acquires its greatest state of depression 
about midnight or before going to sleep. The writer having, in ignorance of 
these investigations, made some experiments of the same nature a few years 
afterwards, he can confirm the results at which Dr. Knox arrived, except that, 
instead of observing actual excitement of the pulse in the morning, he found only 
very marked excitability. Under a careful avoidance of all accidental stimuli, 
such as food, exercise, mental excitation, and the like, he found no difference 
whatever either in the pulse or animal heat in the course of the whole day and 
night; but on awaking in the morning there was so great excitability, that trifling 



464 HECTIC FEVER. 

instances where only one distinct exacerbation occurs, it is observed 
to take place, not during the night, but in the forenoon between ten 
and four ;■ which, however, is a rare circumstance. The paroxysm 
or exacerbation of hectic is essentially a paroxysm of remittent 
fever. The cold stage is often wanting, especially when the disease 
is fully formed. The hot stage is almost invariably followed by 
considerable perspiration, unless means be taken to prevent it. 
The interval is generally one of remission merely, the pulse con- 
tinuing frequent. But sometimes there is an intermission as com- 
plete as in the most characteristic case of ague; and although the 
pulse in the interval may be frequent, the animal temperature is 
often not above the healthy standard. 

In hectic fever the appetite and digestion, though frequently dis- 
turbed in the early stage, are for the most part entire when the 
disease is fully formed, and accompanied with a clear, moist, reddish 
tongue ; but at a later period the stomach often becomes again irri- 
table, vomiting of food is common, and the tongue and fauces are 
often tender and covered with aphthous ulcers. The thirst is sel- 
dom urgent ; the urine usually high-coloured and sedimental ; the 
skin soft, delicate, and easily excited to perspiration ; the bowels 
regular or inclined to constipation. Diarrhoea is often considered a 
symptom of advanced hectic ; but it is not essential, and occurs only 
when inflammation and ulceration of the bowels arise secondarily 
to the primary cause which occasions also the hectic itself. There 
are a remarkable paleness and bloodlessness of the whole integu- 
ments, a pearly appearance and want of vascularity of the conjunc- 
tiva, blanching, and crookedness of the nails ; and during the diurnal 
exacerbation there is a bright red, almost circumscribed spot upon 
each cheek, contrasting strongly with the pallid hue of the rest of 
the body. The debility is commonly great, and always attended 
with progressive and in the end extreme emaciation. Towards the 
latter stage oedema of the ankles and even of the legs is not uncom- 
mon. The mind is seldom impaired till near the close, when mild 
delirium sets in. Previously, however, the mental faculties are not 
merely in general undisturbed, but even in many instances un- 
usually clear and vigorous; and the spirits are upheld by false 
confidence and hopes of recovery. The duration of hectic is ex- 
ceedingly various, and chiefly depends on the progress of its funda- 
mental cause : frequently it endures for many months. 

stimuli raised considerably the pulse and temperature; after mid-day this excita- 
bility gradually decreased: and towards midnight it was lower than at any pre- 
vious period. It is remarkable, therefore, that the ordinary period of greatest 
excitement in hectic fever, continued fever, and many other febrile diseases, oc- 
curs exactly at the time when there is the least excitement or excitability in the 
healthy state of the functions. 



DIAGNOSIS. CAUSES. 465 



II. DIAGNOSIS. 



The diagnosis of hectic fever is an object of much importance in 
practice, both directly on account of the disease itself and its treat- 
ment, and also indirectly for the sake of the inferences which may 
be drawn from its presence and absence in various diseases. In 
some circumstances, for example, the presence of hectic may deter- 
mine the question of the existence of certain organic disorders ; and 
in others, as in chronic pleurisy, it may point out the pathological 
termination of the disease and the nature of the fluid effused. For- 
tunately, it is for the most part easily distinguished from all other 
fevers, by the characters which have just been given above. With 
one form only of fever is it apt at times to be confounded, namely, 
certain varieties of irritative fever, especially those which attend 
chronic internal inflammations. In such cases, however, the febrile 
exacerbations, though frequent, are more irregular in their periods 
than where true hectic prevails ; or where a periodicity is remarked, 
the exacerbations are found to be connected with the excitement 
incidental to digestion. In irritative fever the febricula of digestion 
is often much increased, the pulse being raised twenty pulsations or 
more for some hours after meals, and this state being regularly fol- 
lowed by free perspiration. The same thing is sometimes observed 
in hectic fever, though seldom so remarkably; and, where it does 
occur, there is also the regular and proper exacerbation of hectic 
late in the evening, whether a meal be taken or not. Another cir- 
cumstance connected with fever, which may occasionally cause de- 
ception, is, that sweating often occurs on the patient awaking in the 
morning. In all states of debility the skin is frequently observed 
to be bathed in perspiration as often as the patient awakes. But 
this occurrence is easily distinguished from the sweating of hectic 
by its happening at all times of the day indifferently, and by the 
sweating of hectic taking place whether the patient is asleep or 
awake, and generally indeed before the approach of sleep, in the 
early part of the morning. 



III. CAUSES. 

Much vague discussion has arisen, both among nosographists and 
express authors on hectic fever, as to the causes of this affection. 
It would be unprofitable to reproduce that discussion here. It is 
sufficient to observe, that the doubts and differences which have 
prevailed on the subject seem to have originated mainly in the dis- 
crepant sfatements and opinions of authors respecting the true cha- 
racters of hectic. If the forms of irritative fever, adverted to a 
short time ago, are to be considered as varieties of hectic— namely, 
where exacerbations terminated by sweating occur irregularly, or 
30 



466 HECTIC FEVER. 

present themselves only in connection with the excitement of di- 
gestion, — there is no doubt that the causes of hectic are numerous 
and diversified, and that it might, even with an appearance of just- 
ice, be held with some authors to be occasionally a primary disease. 
But if the characters of hectic be taken as they are commonly un- 
derstood in this country, and as they have been laid down by 
Cullen, then there seems as little room for doubt that the disease 
originates only in connection with suppuration or serious organic 
derangements of structure in the internal viscera ; so that this cha- 
racter may even be correctly admitted into its definition. By con- 
founding together irritative and hectic fever, some modern authors 
have been led to extend the causes of the latter affection to an 
extraordinary degree. Thus M. Broussals gives illustrations from 
his own experience, as well as from the literature of medicine, 
tending to show that hectic may arise from a great variety of gas- 
trointestinal irritations, such as errors of diet, foreign bodies in the 
alimentary canal, especially irritating poisons, diarrhoea, and the 
sequela? of intermittents — also irritations of the pulmonary mucous 
membrane from foreign bodies or chronic catarrh — gonorrheal or 
leucorrhoeal irritation of the mucous membrane of the genital or- 
gans — excessive hemorrhage, or suppression of habitual hemor- 
rhagic discharges— protracted lactation— excessive sweating, and 
extensive chronic diseases of the skin — mental irritation or exhaus- 
tion from excessive study, and violent passions — general bodily 
fatigue — excessive atmospheric heat or cold — and finally from 
organic diseases of internal organs, and suppuration either of in- 
ternal viscera, or in other more external parts of the body. Under 
the direction, however, of a just nosological arrangement and a 
co /ect diagnosis, the greater number of these supposed causes 
must be thrown aside ; and the experience of Cullen is probably 
that of all his successors, that a hectic fever, such as he describes, 
is constantly found to be a symptom of some topical affection, most 
commonly of an internal suppuration. 

The most remarkable and characteristic cases of hectic occur 
along with internal suppuration, such as ulceration of the lungs, 
consequent upon tubercular deposition, purulent effusion into the 
chest, the result of chronic inflammation of the pleura, suppurating 
tumours in the pelvis or abdomen, lumbar abscess and the like. 
Its symptoms are also usually well-marked where the bones are 
affected with caries. Its characters are likewise for the most part 
distinct in malignant diseases, especially scirrhous and fungoid 
tumours, when ulceration is established. The degree or intensity 
of the hectic, however, is not always proportioned to the extent of 
the suppurating surface, the accumulation of pus, or extent of dis- 
charge. In malignant tumours, for example, in caries of the bones, 
and in abscesses formed in the substance of internal organs, the 
hectic is often intense, though the extent of the ulceration or dis- 
charge is insignificant. The usual rule would seem to be, that the 



TREATMENT. 467 

general system sympathizes much less with the extent of the injury 
than with the importance of the affected organ on the one hand, 
and with the malignity of the fundamental disorder on the other. 
Some extraordinary exceptions occasionally occur, as where exten- 
sive suppurations form in the liver, or sac of the pleura, or the 
brain, without hectic fever being produced at all ; but such inci- 
dents are too rare to affect essentially the general law. 

There is likewise no question that hetic fever may be occasioned 
by serious organic diseases without purulent matter being formed. 
Carcinomatous affections, for example, sometimes engender all 
the phenomena of hectic, before they reach the stage of suppura- 
tion ; and the same is observed to occur in regard to some chronic 
inflammations, such as chronic pleurisy and chronic pneumonia. 
In these circumstances, indeed, the exacerbations of fever are most 
generally irregular, so that the febrile state is rather of the nature 
of irritative than of hectic fever. But still the symptomatic affec- 
tion does occasionally put on the characters of true hectic. Hence 
in chronic inflammations, the advent of hectic fever is not so 
unequivocal a sign of suppuration having taken place as many 
practitioners imagine. The writer has repeatedly seen a perfect 
hectic attend chronic peripneumony and chronic pleurisy, where, 
on inspection after death, no trace of suppuration was found, but 
merely general hepatization of the lung in the former case, and 
sero-fibrinous effusion in the latter. In one of the cases of chronic 
pleurisy now referred to, the fluid in the chest was evacuated by 
puncture, in the confident expectation that purulent matter would 
be discharged ; but the only matter which issued was a serum of 
light density, in which fleecy strings of fibrin formed on standing. 



IV. TREATMENT. 

The treatment of hectic fever is necessarily in part subordinate 
to that of the fundamental disease on which it depends. But there 
are likewise certain measures which may be resorted to for mitigat- 
ing more directly the severity of the febrile action. The antiphlo- 
gistic system is inadmissible except in those cases where the disease 
is clearly connected with chronic inflammation not in the advanced 
stage, or where acute inflammatory action, as often happens, is 
excited incidentally. In the generality of cases, an opposite sys- 
tem is rather called for ; and a somewhat generous diet, including 
nutritive articles of food, and even the moderate use of stimulating 
liquids, is found to support the strength without increasing the 
febrile action. In every circumstance, however, the diet should be 
easily digestible and not too abundant, otherwise the stomach is 
enfeebled, and the heat and restlessness of the exacerbations in- 
creased. Tonics are of little service, except where they may be 
found applicable to the fundamental disease, or are required to cor- 
rect the tendency to dyspepsia, which occasionally prevails at the 



468 HECTIC FEVER. 

commencement. In the latter case simple bitter infusions, such as 
of quinia, gentian, or calumba, with or without the alkaline bicar- 
bonates, are commonly found to answer best. [Quinine may often 
be administered in hectic fever with great advantage. If the sto- 
mach will not tolerate it, the cold infusion of red bark, made 
by displacement, will be found an admirable substance.] The 
patient ought to be confined in cold weather to apartments main- 
tained at a uniform and moderate temperature ; and at night, 
when the sweating stage of the exacerbation approaches, the bed- 
clothes should be diminished so far as is consistent with his feel- 
ings. In mild weather, however, and in a suitable climate, great 
advantage is found in persevering with gentle out-of-doors' exer- 
cise, as long as the strength will permit. Nothing contributes so 
much to the patient's comfort, both at the time and for the rest of 
the day ; and, in particular, the restlessness in the evening and the 
subsequent perspiration are better mitigated in this than in any 
other way. One of the most important objects of treatment in 
hectic is the diminution of colliquative sweating. In addition to 
the means already pointed out for this purpose, it is found that ad- 
vantage is sometimes derived from the tepid sponging of the head, 
face, chest, and arms, in the early part of the night before the 
sweating stage sets in. Of all internal remedies for the same end, 
none equals the sulphuric acid, which in this way is one of the 
most efficacious astringent refrigerants. The restlessness and want 
of sleep must be met with anodynes. These, indeed, are in general 
rendered also necessary by the cough, pain, or other uneasiness 
arising directly from the primary local disease. The whole list of 
narcotics has been had recourse to in such circumstances. Hydro- 
cyanic acid in frequent small doses is sometimes decidedly service- 
able ; tea is commonly of some use; hyoscyamus, or some of the 
other solanaceous narcotics, is also often effectual ; but the most 
efficient of all, and that to which all resort, sooner or later, is 
opium, or a salt of its alkaloid. The great objection to opiates is 
their tendency to increase the sweating, which the conjunction of 
sulphuric acid does not always correct. Frequently, however, there 
is no alternative, as nothing but opium or morphia will obtain sleep 
or quiet. The compounds of morphia have the same advantage 
over the Galenical preparations of opium in this as in other dis- 
eases. This is not the place to enter into the treatment of the affec- 
tions incidentally concurring with hectic, and arising secondarily to 
its fundamental cause. But it may be mentioned, that the best 
method of counteracting the diarrhoea, which is thus so often asso- 
ciated with hectic, is by the administration of considerable doses 
of acetate of lead with small doses of opium, such as one or two 
pills, twice or even three times a day, prepared like the lead and 
opium pill of the Edinburgh Pharmacopoeia. No other treatment 
is so frequently and so promptly successful in arresting the diar- 
rhoea, or is attended with so little risk of increasing the vicarious 
discharge by perspiration. 



469 



CHAPTER X. 

SMALL-POX. 

[Syn. — Variola, Variola, Pestis Variolosa; Variole, Petite Verole, Picote, Fr.; Echten 
" Blattern, Natusliche Blattern, Menschenpocken, Menschenblatternkrankheit, Kinder 
Blattern, Kinder pocken, Germ.] 

Small-pox may be thus defined : — A fever commencing with 
sickness, headache, pain of the back, and general lassitude, followed 
on the third day by an eruption on the skin of pimples, more or less 
extensively diffused, which in the course of a week inflame and 
suppurate, accompanied in many instances by a similar affection of 
the mucous membrane of the nose and mouth ; in some by swelling 
and inflammation of the subjacent cellular membrane, and occa- 
sionally by affection of the nervous system. The several kinds of 
small-pox which have been described by authors have reference, 
1, to the nature of the accompanying fever ; 2, to the quantity and 
aspect of the eruption ; 3, to the concomitant and superadded symp- 
toms. 

The following are the principal varieties of small-pox mentioned 
by the best authors : — 1. Variola discreta ; 2. Variola confluens; 
3. Variola semiconjluens ; 4. Variola coherens, or corymb os a ; 5. 
Variola regularis, or benigna ; 6. Variola maligna ; 7. Variolas 
anomaloe, under which head are included small-pox with affection 
of the brain, small-pox with affection of the chest, small-pox with 
diarrhoea, or dysentery. Small-pox is said to be distinct when the 
pustules admit of being counted, being placed at such distances 
from each other as not to coalesce, or run into each other, even 
when fully maturated. It is called confluent when the pimples are 
so close set as to run into each other on the third or fourth day of 
inflammation. The terms clustered, coherent, or corymbose small- 
pox is applied to that form of the disease where the pimples are 
confluent in patches, the patches being, however, separated by in- 
tervals of unaffected skin. Small-pox is said to be semiconfluent, 
when the papulae are so far separated from each other that they do 
not coalesce generally until the full period of pustulation. 

The phenomena of small-pox, in all its forms and varieties, admit 
of a natural and useful division into four stages : — The first is the 
stage of incubation, extending from the reception of the variolous 
germ to the invasion of fever. The second is the stage of initiatory 
or eruptive fever, occupying three or four days. The third is the 



470 SMALL-POX. 

stage of maturation, extending from the development to the full 
maturation of the pustules, a period varying from five to nine days. 
The fourth is the stage of decline, desiccation, and secondary fever. 
We shall begin by detailing the phenomena observable in an 
attack of distinct but full small-pox, occurring to a young person 
in the prime of life, unvaccinated, of good constitution, without 
any peculiarity of temperament, or disposition of blood and hu- 
mours likely to interfere with or modify the ordinary train of symp- 
toms. This being done, we shall proceed to show what are the 
characteristics of the other varieties of small-pox usually noticed 
by authors, and the modifications produced in the symptoms by 
difference of age, habit, previous condition of body and mind, and ? 
lastly, by previously undergoing vaccination. 



A. VARIOLA BENIGNA DISCRETA. 
I. INCUBATION. 

It is observed by Rayer, in his valuable treatise on the Dis- 
eases of the Skin, that this period (during which the system, after 
imbibing the variolous germ or poison, is preparing for its elimina- 
tion) presents for the most part no morbid symptoms either of a 
general or local nature. The usual accuracy of this author is not 
well displayed here. The fact is, that a variety of circumstances 
distinguish this period, commonly known to nurses as the period 
when the small-pox is breeding. In many cases the patient expe- 
riences at the moment of imbibing the germ or contagion some dis- 
agreeable feeling, such as an unpleasant odour, a sense of giddiness, 
sickness, or an inward sense of alarm and fright. The succeeding 
days are passed differently in different cases. Sometimes little or 
no inconvenience is felt ; at times, however, there is present a cer- 
tain degree of languor and lassitude ; the patient is low-spirited, 
and disinclined to exertion ; the nights are restless, and the diges- 
tion somewhat impaired. The usual duration of the incubative 
stage of small-pox is twelve days, but it is difficult to assign the 
maximum and minimum limit : possibly it may extend from seven 
to fourteen days. 

II. INITIATORY OR ERUPTIVE FEVER. 

On the eleventh or twelfth day from the reception of the vario- 
lous germ, rigors announce the setting in of the initiatory or erup- 
tive fever. Sometimes one severe and long-continued shivering fit 
indicates to the practised physician the coming events : at other 
times the rigors are less violent and recur irregularly. They are 
soon succeeded by the common evidences of pyrexia : — general 
pains of the limbs, a quickened pulse, diminished secretion, a hot 



INITIATORY OR ERUPTIVE FEVER. 471 

skin, with dryness or disposition to sweating. But there are cer- 
tain other symptoms very characteristic of incipient small-pox. 
They may be thus enumerated : — severe pain, or weakness as it is 
sometimes called, in the back, so that the patient has suddenly 
dropped down. We have known a female attacked about the 
expected period of parturition with such excruciating pain in the 
loins, that labour was momentarily expected. It proved to be the 
onset of severe semi-confluent small-pox.* Frequently the ence- 
phalon suffers. There is pain of the head generally, or pain refer- 
red to the temples. Among children a state of somnolency is fre- 
quently noticed, and they wake with a start or fright. The nervous 
system sometimes participates in a degree still more striking : — a 
child is unexpectedly seized with a perfect epileptic paroxysm ; the 
adult becomes delirious, or falls into a state of stupor, and he may 
well be imagined on the eve of some severe cerebral affection ; the 
face is flushed; the action of the heart is rapid and tumultuous. 
In some cases the stomach is the organ which first takes alarm from 
the impending evil. There is acute pain of the stomach present, 
aggravated by pressure, and accompanied by such incessant vomit- 
ing that the physician, not without reason, suspects the presence of 
gastritis, and directs the loss of blood and the infliction of a blister. 
The irritable condition of the stomach frequently continues through 
the whole period of initiatory fever, and is not entirely subdued 
until the eruption has extended over every part of the surface, even 
to the legs and feet. In almost all cases there is marked prostration 
of strength. The expression of countenance is anxious : in some 
instances, where the habit is weak, there is an almost total collapse. . 
The pulse is feeble, the skin pale, contracted, and cold : wine and 
cordials are here urgently required to keep the patient from irre- 
mediable exhaustion. All these more urgent symptoms, however, 
indicate, for the most part, the approach of a severer form of the 
disease than that which we are now describing. The pain of the 
back and loss of muscular power are the symptoms, from the com- 
parative mildness or severity of which the best prognosis may be 
formed. 

The phenomena now enumerated as the chief features of the 
eruptive fever of variola may be so variously combined, that it is 
often difficult to say on which organ or structure the poison has 
fixed itself in greatest force. Such symptoms may cease altogether 
with the appearance of eruption, or they may continue to harass 
the patient, in varying degrees of intensity, through the greater part 
of the next stage, that of maturation. 

The duration of the initiatory fever of small-pox is one of the 
most important points in its history. By it alone the diagnosis is 
in many cases accurately established, and it will always attract the 

*[ Dr. Chomel regards the lumbar pains, which he refers to the kidneys, as pa- 
thognomonic of variola.] 



472 SMALL-POX. 

especial attention of the physician. It has proved, however, a fruit- 
ful source of controversy among authors. Prior to the time of 
Sydenham, it was thought desirable to shorten the period as much 
as possible, and this was attempted by the employment of heating 
diaphoretics. Sydenham again believed (chap. ii. p. 34) that " the 
more time nature employed in finishing the separation of the in- 
flamed particles, the greater was the chance of ultimate success in 
the cure." There is little ground for either opinion. The period 
of initiatory fever is singularly uniform : in a large proportion of 
cases the eruption shows itself at the end of forty-eight hours from 
the occurrence of rigor, pain of back, or sickness, whether the 
subsequent symptoms be mild or malignant, the eruption distinct 
or confluent. This period may be lengthened from weakness of 
habit, the loss of blood, long-continued vomiting, or extreme cold ; 
but, so far as our experience extends, it is never shortened. 

The time occupied in the development of the eruption is liable 
to considerable variety. It is usually completed over the whole 
"body in one or two days, but from accidental circumstances, like 
those which protract its first appearance, it may extend over a 
period of three or even four days. In a great proportion of cases 
the eruption of small-pox develops itself in the following manner :— 
Minute papula?, sensibly elevated above the surface of the skin, 
first show themselves on the face and forehead. It is only in a 
very few instances that the eruption commences in the inferior 
extremities: it is seldom distributed in equal profusion over the 
whole skin. It often happens that one or two papulse precede the 
general eruption, and have advanced to the state of vesicle before 
the surface is extensively occupied. 

The sides of the nose, chin, and upper lip, generally display the 
earliest pimples : then some are perceived on the neck and wrists : 
by degrees the trunk and thighs are occupied with eruption, the 
feet being almost invariably the part latest affected. With the 
completion of eruption terminates the second stage of small-pox, 
the initiatory stage, or fever of invasion. 

III. MATURATION. 

In all cases of distinct small-pox, and in a large proportion of 
cases of the semiconfluent kind, the constitutional symptoms expe- 
rience a marked relief when the eruption is fully developed : — the 
pain of the back, the vomiting, and the headache abate, or disap- 
pear entirely: the respiration becomes less hurried; the pulse di- 
minishes both in force and frequency ; there is less jactitation and 
restlessness, and not unfrequently the patient gets some sleep. 

On examination of the papulae it will be found (where opportu- 
nity is given for observation by the moderate quantity of the erup- 
tion) that they are not thrown together confusedly and without 
order, but that they are arranged in groups of three or five, as- 



ANATOMICAL CHARACTERS OF THE VARIOLOUS VESICLE. 473 

suming often a crescentic shape. Two or more groups coalescing 
form, in some cases, a complete circle of papulse. 

IV. ANATOMICAL CHARACTERS OF THE VARIOLOUS VESICLE. 

Great attention has been paid by modern authors to the anatomy 
of the skin under small-pox. Cotugno commenced the investiga- 
tion, which has since been diligently followed up by John Hunter, 
Dr. Adams, Mr. Cruikshanks, Dr. Craigie, and various conti- 
nental authors, more especially Dr. Petzholdt. A full account 
of the latest views on this subject may be found in the Brit, and 
Foreign Med. Rev., vol. v., p. 470. 

The following is a brief sketch of the opinions now entertained 
as to the structure of the variolous pock. The inflamed spot (phlyc- 
tidium) has its seat in the cutis vera. It commences on a central 
point called the stigma, spreads by radiation on the surface, and 
penetrates in different cases to a greater or less depth. Beneath 
the epidermis, and constituting the greater part of the phlyctidium, 
is found a substance of a consistence like pulp or thick mucus — a 
sort of pseudo-membranous layer, or disc, which is not considered 
as any part of the skin itself altered by disease, but as a new pro- 
duct. This substance was known to John Hunter, by whom it 
was called the variolous slough. The vesicle, when further exam- 
ined, is found to be divided into numerous cavities or cells : it is 
multilocular. The floor of each phlyctidium presents the papil- 
lated structure of the skin elevated and marked with fissures and 
chinks. At the height of suppuration this part is swelled, and moist 
like a sponge. The fluids, (lymph and purulent matter,) which at 
different stages of its course distend the cells of the phlyctidium, 
are thrown out by vessels which shoot from the red central point 
or stigma. This point may readily be detected on the vesicles of 
the face and trunk (at least on the greater portion of them) by a 
depression on the surface of the vesicle, where the chorion and epi- 
dermis adhere. This central depression, abundantly obvious in 
most cases to the naked eye, is in an early stage of the disorder 
made more manifest by the microscope. It gives that peculiar 
umbilicated form to the variolous vesicle, which is the great charac- 
teristic of small-pox. 

The inflammation of the phlyctidium is accompanied by an 
areola or halo of a damask-red colour, more or less vivid according 
to circumstances, and which extends to some distance beyond the 
margin of the vesicle. The secreted fluid, at first thin and limpid, 
distends in the first instance, and elevates above the level of the 
surrounding skin the sides of the vesicle. At length the filament- 
ous attachment of the stigma to the cuticle is destroyed, the central 
depression ceases to be observed, the pustule acuminates and ulti- 
mately bursts, discharging a well-formed purulent matter of the 
consistence of cream, and of a yellowish colour. 



474 SMALL-POX. 

Leaving these anatomical minutiss for matters of more direct 
practical application, it may be observed that the maturation of 
each individual phlyctidium occupies, in the class of cases now 
under consideration, (the regular distinct benignant,) a period of 
seven days. It is seldom, however, that the condition of the erup- 
tion is uniform over any large extent of surface. The pustules on 
the face and neck usually attain their proper size, and discharge 
their contents first, then those of the trunk and upper extremities, 
while the parts at a distance from the centre of circulation are slow 
in reaching maturity. Three, four, or even five days, therefore, 
may intervene between the period when the pustules begin to burst 
on the face and the perfect maturation of those on the feet. 

The constitutional symptoms present during the period of matu- 
ration (or concoction) vary greatly in severity. When the pustules 
are numerous, there is both general fever and local irritation ; the 
pulse is accelerated ; the nights are restless ; the urine is scanty and 
high coloured ; frequently there is delirium, especially at night. 
Much, however, will depend on the quantity of eruption, the 
habits of the patient, and the circumstances under which he is 
placed. If the habit of body be good, the blood of healthy quality, 
without plethora ; if the season be mild, the apartment cool, and 
the diet carefully restricted ; if, lastly, the mind of the patient be 
tranquil, a large mass of eruption may maturate with a very mode- 
rate degree of fever. In many cases, however, there is great local 
irritation; the skin is often so tender as to occasion the utmost 
distress ; frequently there is great itching of the surface, so that the 
patient is with difficulty restrained from scratching and abrading 
the tender vesicles ; the face is often swelled, and the eyelids closed 
during the three or four days which precede the bursting of the 
pustules. A similar swollen condition of the hands is often pro- 
ductive of great inconvenience. Throughout the whole period of 
maturation, but especially at the height, the surface of the body 
throws out a peculiar faint and sickly smell, quite peculiar to this 
disease. 



V. DESICCATION AND DECLINE. 

On the eighth day from the appearance of eruption, the inflamma- 
tory areola subsides, and the ripened pustules having burst and dis- 
charged their contents, are succeeded by scabs which dry up and, 
in a healthy state of constitution, fall off in the course of four or five 
days. In mild cases, where the full process of pustulation is not 
gone through, many of the vesicles become shriveled, and form 
only imperfect and scaly crusts. Occasionally these imperfect scabs 
may be seen intermixed with the scabs of well-developed pustules ; 
and it often happens that, on the lower extremities, this premature 
desiccation of the vesicles shall be very general. The phenomenon 
has been attributed almost universally to the absorption of the 



VARIOLA CONFLUENS. 475 

purulent matter. But it is not so. No matter is formed : the 
serous fluid secreted during the first days of inflammation does not 
undergo any further change ; it condenses in the serous form ; the 
cuticle over it shrinks ; and in this manner a dry scaly crust is 
formed. About the fourteenth day of eruption, the fever has en- 
tirely subsided, all swelling of the face has ceased, the crusts have 
fallen from the face and upper parts of the body ; but the surface 
of the skin, especially of the face, is left of a reddish brown or 
vinous tint ; and occasionally, where ulceration has succeeded the 
bursting of the scab, depressions are perceived. The -clarety hue 
of the skin left by small-pox often continues for many months. 
The pits or depressions (foveolse) are permanent in after life. From 
the great vascularity of the face, there is always most risk of such 
disfigurement in that part. 



B. VARIOLA CONFLUENS. 

The extraordinary difference between the distinct and confluent 
forms of small-pox have been observed by all authors since the 
disease was first an object of study. It is not merely that the skin 
is here more crowded with papulae, but other features of the com- 
plaint are observable, which in the distinct form are absent or 
scarcely perceptible. The following brief enumeration of the pecu- 
liarities of the confluent small-pox will prepare the way for that 
more detailed investigation which the importance of the subject 
demands: 1. The eruptive fever is more intense. 2. The regular 
course of inflammation in the vesicles is interfered with by the im- 
mense quantity of papulse which occupy the skin ; the inflammation 
extends to the subjacent cellular texture. 3. The mucous expan- 
sions of the nose, mouth, pharynx, larynx, and trachea, are the 
seats of eruption equally with the skin ; and this complication 
materially influences the progress and appearances of the cutaneous 
inflammation. 4. The nervous system participates in the general 
disturbance. 5. The febrile symptoms continue, and even increase 
in intensity, from the first appearance of eruption to maturation. 
6. The decline of the disorder is accompanied by secondary fever. 

1. In confluent small-pox the eruptive fever is for the most part 
very severe : the pain of the back and muscular weakness are ex- 
cessive ; the patient staggers in his walk ; the expression of coun- 
tenance is haggard ; at times there is, from the very first, a strongly 
marked implication of the brain and nervous system ; delirium is 
observed, sometimes fierce, sometimes of the typhomaniacal cha- 
racter, or the patient is comatose ; the respiration is laborious ; the 
pulse frequent, small, contracted, or oppressed ; and there is con- 
stant sickness at stomach. Sydenham (sect. iii. chap, ii.) and other 
authors have described confluent small-pox as ushered in with 



476 SMALL-POX. 

diarrhoea, and general irritation of the mucous membrane of the 
alimentary canal : we have rarely met with this occurrence. 

2. The immense number of papula? thrown out on the surface is 
undoubtedly the leading feature of confluent small-pox, and one 
great cause of danger. The extreme vascularity of the face leads 
often to confluence there, while other parts may be comparatively 
free. Still the disease is called confluent, and the progress of erup- 
tion on the face becomes the index which chiefly guides the judg- 
ment of the physician. Sometimes, however, confluence is confined 
to one arm, to one leg or foot, or to the breast. These cases are 
comparatively much less dangerous. 

In all cases extreme confluence interferes materially with that 
due progress of cutaneous inflammation, on which the safety of the 
patient mainly depends. There is no areola, no central depression. 
As early as the third day, the face appears covered with a thin 
cutaneous whitish pellicle, a kind of membranous exudation similar 
to that which is observed at the bottom of isolated pustules. The 
inflammatory action thus checked in its regular course, dips inward, 
and invades the subjacent cellular membrane. The face and head 
about the third day begin to swell ; the salivary glands become 
involved, and ptyalism sets in, which often continues until the 
eighth or tenth day. The cellular membrane throughout the body 
generally, participates (more or less, according to the number of the 
papulae on the surface) in the same affection. There is tension of 
the limb, often to a great extent, and an erythematous redness 
occupies such parts as are free from papulae. In some aggravated 
cases buboes form in the groin with intense pain. The scalp is 
often very tumid, a symptom from which much danger is to be 
apprehended. Phymosis and paraphymosis, and a swollen state of 
the scrotum, are attributable to the same general condition of the 
body. The face about the eighth day presents the appearance of 
one flat and doughy sore, which discharges a copious thin ichor. 
An intense pruritus accompanies the formation of the scabs, which 
often induces patients to tear themselves with their nails. In child- 
ren especially this is noticed, as the numerous black, bleeding, and 
excoriated points observable on the face amply testify v Very many 
patients die between the eighth and twelfth day of the eruption, 
from the combined effects of cutaneous and cellular inflammation. 

3. In almost all cases of confluent small-pox there is an affection 
of the mucous tissues, which adds largely to the danger. This 
inflammation of the mucous membranes constitutes an important 
element in the character of variola, and will require separate ex- 
amination. The mucous membrane of the nose, mouth, pharynx, 
larynx, and trachea, are the parts thus affected ; the tongue is also 
implicated ; papulae show themselves on these parts simultaneously 
with the cutaneous eruption. The mucous vesicles may be distinct, 
confluent, or semiconfluent; they run the same course as the cuta- 



VARIOLA CONFLUENS. 477 

neons vesicles, coming to maturity, like them, on the seventh or 
eighth day. The symptoms occasioned by this mucous affection 
are as follows : — Numerous white points appear on the tongue, 
palate, and velum pendulum ; the membrane of the mouth is red 
and injected ; there is a distressing heat in the mouth, difficulty of 
swallowing, pain in the throat, sense of stuffing in the nose, hoarse- 
ness, and cough ; the occurrence of hoarseness marks the implica- 
tion of the larynx, and its increasing severity may be taken as a 
just index of increasing danger ; the cough is first dry, hard, painful, 
and tearing ; as the disease advances, it is accompanied by mucous 
expectoration. About the eighth day, a copious viscid secretion 
takes place from all the affected structures ; but in a large propor- 
tion of such cases the swelling has by this time extended to the 
parts about the larynx, and the effused fluids have so blocked up 
the trachea and air-passages, that respiration is materially impeded, 
the due oxygenation of the blood interrupted, and suffocation 
threatened. The progress and aspects of the cutaneous eruption 
are necessarily modified by the mal-oxygenation of the blood ; the 
areola, on parts at a distance from the heart, is either altogether 
wanting, or is of a clarety or livid colour ; the pustules are every- 
where flat ; — they do not fill or acuminate well, even on the neck 
and breast; the extremities are cold ; the tongue is swelled, and of 
a purple hue. In addition to the increasing dyspnoea, a low mut- 
tering delirium is observed, at first present only at night, afterwards 
permanent through the day ; restlessness and anxiety increase ; and 
between the eighth and tenth day from the first appearance of erup- 
tion, the patient dies. 

4. In a certain proportion of cases of confluent small-pox the 
brain and nervous system are implicated in a degree far beyond 
what the general febrile disturbance would seem to warrant. From 
the first there is delirium, of that kind called by the old authors 
delirium ferox. It is marked by a strong disposition to self-injury, 
so that the utmost caution is necessary to guard against accident : 
restraint is indispensable. Variolous delirium is sometimes accom- 
panied with redness of the eye, contracted pupil, and a wild ex- 
pression of countenance. The pulse is sharp, and the carotid 
and temporal arteries beat strongly ; but it is seldom associated 
with plethora, and the loss of blood rarely gives relief. It is often, 
however, present without any of these evidences of arterial action ; 
it is to be viewed, therefore, as a peculiar affection of the nervous 
system, the result of the variolous poison in irritable habits. As 
it ushers in the disease in a certain number of cases, and continues 
during the first days of fever, so does it almost invariably decline 
about the sixth or seventh day, when the maturation of the pus- 
tules commences. Excessive restlessness, anxiety and despondency 
of mind, are evidences of the same irritable condition of the ner- 
vous system. All these are symptoms of great danger. A large 



478 SMALL-POX. 

proportion of such cases terminate unfavourably, some by coma, 
some by supervening erysipelas, some by acute inflammation of an 
internal organ (the pleuritic surface of the lung in particular) 
brought on, or determined by, the state of the brain. To this 
variety of small-pox Burserius and Frank have given the name of 
variola nervosa. Though generally associated with a full and 
confluent form of eruption, yet this is not essential ; and it is some- 
times found that intense delirium accompanies, and of course mate- 
rially aggravates, the danger in distinct and semiconfluent cases. 

5. In confluent small-pox the febrile symptoms experience no 
mitigation on the appearance of eruption. Throughout the whole 
period of maturation the pulse continues frequent, the skin hot, the 
thirst great ; during the day the patient tosses about the bed restless 
and uneasy ; his nights are passed without sleep, frequently with 
delirium : there is great weakness of the muscular fibre. As the 
disease advances to its crisis, symptoms of increasing cerebral irri- 
tation manifest themselves ; the tongue becomes dry, and is pro- 
truded with difficulty and tremor ; the stools and urine are passed 
involuntarily, or the urine is retained in the bladder ; subsultus 
tendium and picking of the bed-clothes follow, and death takes 
place as in cases of typhoid fever implicating the brain. 

6. The last peculiarity of the confluent form of small-pox is to 
be found in the symptoms which accompany the period of desicca- 
tion and decline. Many cases, indeed, die between the eighth and 
tenth days of the eruption ; some, as we have pointed out, from 
affection of the brain ; some from extensive disorganization and 
destruction of the skin and subjacent cellular texture ; some from 
laryngeal complication, and consequent mal-oxygenation of the 
blood. But a certain number, partly from original strength of 
constitution, partly from a less intensity of disease, survive these 
critical days to enter on a new trial. The restorative process 
has commenced, but the struggle is attended with great constitu- 
tional disturbance, known to physicians by the name of the second- 
dary fever. 

The secondary fever supervenes chiefly in cases where the 
cellular membrane over the body has become extensively involved 
with the skin in inflammation, and where the mucous complica- 
tion has been comparatively mild. Under such circumstances the 
strongest habits will suffer under the secondary constitutional dis- 
turbance : but many children, and some adults of weak habits, fall 
into it, with only a moderate extent of superficial inflammation. 
The state of the surface, therefore, and that of the constitution, are 
alike to be taken into account, when estimating the probability of 
its occurrence, and the danger when it has set in. 

The symptoms of secondary fever may be thus enumerated : — 
The surface becomes hot and dry; the pustules hard and scaly; 
the tongue white ; the pulse rapid ; the patient gets no sleep, and is 



VARIOLA CONFLUENS. 479 

tormented with an inextinguishable thirst. The evils of secondary- 
fever, however, do not terminate with these evidences of inward 
tumult. In almost every case the violence of the fever falls on some 
one part; and the following is an attempt to classify the usual phe- 
nomena : — 

1. In a very large proportion of cases the impetus of the fever is 
thrown upon some part of the superficies ; nor need we wonder that 
parts already weakened and prone to inflammation, should be the 
first to suffer. An efflorescence, identical with scarlatina, occupies 
the chest, back, or extremities. The tongue is morbidly red, and not 
unfrequently the throat is red, swollen and painful. In other cases 
the cutaneous affection assumes the form of erythema, which in 
bad cases passes into confirmed erysipelas, with extensive vesica- 
tions and high constitutional excitement. The head, trunk, and 
extremities are all equally subject to this kind of attack. Sometimes 
the cutaneous and cellular inflammation is more circumscribed; 
boils, abscesses, and carbuncles, occur in the neck, axillae, groins, 
elbows, and thighs. In certain cases gangrenous inflammation 
attacks a large portion of the skin, especially the legs and feet, 
which in a few days lays bare the subjacent muscles. The same 
affection frequently shows itself in the first instance on the scrotum 
and prepuce, runs on rapidly to destruction of the part, and gener- 
ally ends fatally. In parts exposed to pressure, especially the back 
and hips, sloughy ulcerations often take place, which, from their 
extent and depth, bring life into imminent hazard. In some cases 
the scalp is affected with diffuse cellular inflammation, and the head 
is immensely swollen ; sometimes very deep-seated parts take on 
a like action. We have met with abscess beneath the scapula. 
In some few cases the larger joints fill with purulent matter. The 
disposition in inflamed parts, during the secondary fever of small- 
pox, to terminate in the effusion of pus, appears to be universal, 
and almost uncontrollable. In a certain proportion of cases the 
surface is occupied with a pustular eruption of the ecthymatous 
kind. It ends in the formation of ulcers pouring out a thin ichor, 
which heal with great difficulty. The thin cellular membrane 
under the lower eyelids is the frequent seat of such indolent sores. 

2. Another structure which receives the shock of the secondary 
fever is the eye. Variolous ophthalmia is a subject of great extent 
and interest, and might claim for itself separate investigation ; but 
as this form of ophthalmia is fully considered in works on ophthal- 
mic surgery, we shall only offer a few details, the result of our own 
observation. 

Variolous ophthalmia is often stated to arise from pustules on the 
cornea formed at the same time, and in the same way as pustules 
on the skin. This however is an error. Ophthalmia indeed some- 
times attends the early stages of small-pox, but it is common con- 
junctival ophthalmia. Pustules of a true variolous character do not 



480 SMALL-POX. . 

form upon the conjunctival membrane : they may be traced just 
within the inner edge of the palpebrae, but not beyond it. The 
true variolous ophthalmia, by which sight is so frequently destroyed, 
is a sequela of small-pox : an incident in the progress of secondary 
fever, and almost always coincident with abscesses of extensive 
destruction of the surface in some distant part. It is an intense 
form of ophthalmia, setting in generally about the tenth day, and 
rapidly involving in destruction, more or less complete, some one or 
all the tissues of the eyeball. There is, first, sloughing of the cor- 
nea, followed by staphylomatous protrusion of the iris. In other 
cases the cornea thickens and becomes opaque, but by degrees, 
and in the course of two or three years, recovers entirely, or more 
or less completely, its transparency. Sometimes the whole ball of 
the eye takes on rapid and violent inflammation, and is converted 
into one immense protruding abscess. It is comparatively rare to 
meet with more than one eye involved in this destructive form of 
inflammation ; but in all countries, and from the very earliest periods 
at which we read of small-pox, we meet with cases of total blind- 
ness ascribed to this disease. Not more than three cases of total 
blindness have left the Small-pox Hospital in the course of the last 
twenty years. Several other cases of double destructive ophthalmia 
have indeed occurred, but they all proved fatal from the severity of 
the accompanying disorders. 

3. It is not to be supposed that fever, such as that we are now 
treating of, can rage without occasionally affecting the interior of 
the frame. The brain sometimes suffers. Children are observed 
to grind their teeth, and squint. By degrees the symptoms of cere- 
bral inflammation are developed, and the child dies either in an 
epileptic fit, or in the state of coma. Adults may also occasionally 
be seen labouring under true phrenitis ; and some, of plethoric habit, 
about the eleventh or twelfth day, become lethargic and ultimately 
comatose, vascular congestion having taken place in the brain. 
There is another condition of the brain and nervous system not 
unfrequently observed in the progress of secondary fever. It is 
identical with that which accompanies the destruction of large por- 
tions of skin by fire, and which is familiar to surgeons as the con- 
sequence of extensive burns and scalds. The symptoms are severe 
and repeated rigors, followed by general tremors, low delirium, a 
quick, thready, tremulous pulse, a dry brown tongue, collapse of the 
features, cold extremities, subsultus tendinum, and death. 

4. In a certain number of cases the thoracic viscera suffer while 
the system is labouring under secondary fever, and the pleura (cos- 
talis and pulmonalis) is the structure which usually takes on diseased 
action. No obvious cause can be assigned for the occurrence of 
variolous pleurisy in the majority of cases. It often sets in "most 
unexpectedly between the seventh and fourteenth days of eruption. 
In general its course is very rapid, terminating fatally on the third 



VARIOLA CONFLUENS. 481 

or fourth day. We have seen it prove fatal in thirty-six hours. The 
symptoms are for the most part very urgent and unequivocal. 
There are agonizing pain of the side, extreme dyspnoea, with a hard, 
wiry, and incompressible pulse. The patient dies in great suffering, 
and on dissection the corresponding cavity of the chest is found 
filled with pus, or a sero-purulent fluid. In other cases, the symp- 
toms are less violent, presenting at first the characters of pleurodyne 
or thoracic rheumatism. It is, however, to be kept in mind, that 
variolous pleurisy is sometimes unattended by prominent local 
symptoms. The disease is chronic and latent. Auscultation alone 
detects its existence. We have seen cases where acute rheumatism 
and hernia humoralis formed the only urgent symptoms during life, 
but on dissection one cavity of the chest was filled with pleuritic 
effusion. This will serve to show the importance of a careful and 
accurate exploration of the chest in all suspected and doubtful cases ; 
though it is right to add, that these insidious internal inflammations, 
occurring while the system is labouring under intense fever, hardly 
admit, even if detected during life, of effectual relief from any mode 
of treatment. 

The substance of the lungs has been found, in some few cases 
of secondary fever, to have been the seat of acute inflammation. 
Children are often attacked with symptoms of croup, and elderly 
persons are sometimes carried off by laryngitis. These cases are, 
however, very rare. 

5. The abdominal viscera are, in a very remarkable manner, ex- 
empted from the ravages of small-pox. Sometimes we see children, 
in the course of secondary fever, labouring under the common sub- 
acute form of muco-enteritis, the belly tender, the stools ejected with 
force, the tongue red and aphthous. In a few cases, the peritoneal 
surface of the liver may be observed taking on inflammatory action ; 
but the abdominal complications present no peculiar features, and 
require no specific notice. 

6. The decline of small-pox is frequently mixed up with other 
evils not flowing from the same source, but arising either from the 
peculiarity of the patient's habit, or the circumstances under which 
he is placed. Thus it is that small-pox is so frequently seen at this 
period of its course, conjoined with scrofula. Nothing serves so 
certainly to call into activity the dormant seeds of scrofula as an 
attack of small-pox. Accordingly, we find the period of convales- 
cence protracted by strumous ophthalmia, known by the complete 
intolerance of light, the forcible closure of the eyelids, the abundant 
secretion of tears, and an obstinate resistance to every kind of re- 
medial treatment. We find, in like manner, at this period, enlarge- 
ments of the cervical glands, which sometimes suppurate, but more 
often continue hard, indolent, and intractable. Severe otitis arises 
in such habits from accidental exposure to cold. Scrofula develops 
itself in the joints or invades the bones. It happens but too often, 

31 



482 SMALL-POX. 

that the seeds of tubercle and pulmonary phthisis are laid during 
the progress of small-pox, and especially when the secondary fever 
has been severe and tedious. 

[Hemorrhage is by no means an unfrequent complication, and is 
a very dangerous one. It occurs generally in the abnormal forms 
of the disease. Epistaxis, happening early in the attack, and which 
is generally of the active kind, must not be confounded with the 
dangerous passive fluxes in the malignant varieties. Any organ 
may be the seat of the hemorrhage, but it is rarely abundant with- 
out the skin participating. Next to the skin the various mucous 
membranes generally furnish the blood, then the lungs, and after- 
wards the urinary apparatus, and muscular system. From the 
third to the fifth day, is the most common epoch of its appearance. 
When the skin is affected, the effused blood may occupy the 
pustules themselves, their circumference, or the intervals between 
them.] 

Lastly, the decline of small-pox may be complicated with fever 
of a different character, attributable, not to the variolous poison, 
but to some miasm generated by the accumulation of malignant 
cases, and received into a system already weak and exhausted. 
To this source some part of the mortality in all hospitals devoted 
to the reception of small-pox must in fairness be attributed. Vitia- 
tion of the air is almost inseparable from the nature of an hospital, 
and the offensive exhalations from the surface in small-pox are pre- 
eminently calculated to generate a noxious febrific miasm. Hospital 
fever, as it may well be called, thus originating, attacks all persons 
within its influence. It shows itself under the following aspects : — 
1. Typhus Fever ; 2. Erysipelas; 3. Inflammation of the mucous 
membrane of the throat and of the subjacent cellular membrane ; 
4. Hospital gangrene. One or more of these very formidable com- 
plaints may attack persons during the secondary fever of small- 
pox, or as they gradually emerge from it. It is unnecessary to say 
how fearfully the danger of the patient is thereby increased. The 
mildest forms of small-pox are not exempt from this additional 
calamity. 

Having now described the two principal varieties of small-pox, 
we proceed to explain the distinctive characters of certain others 
which have been noticed by authors, and to which specific appel- 
lations have been attached. We shall enumerate them in the 
following order : — 1. Variola semiconfluens ; 2. Variola corym- 
bosa ; 3. Variola maligna ; 4. Variolse anomalse ; 5. Variola 
conjluens •mitigata, sive Variola verrucosa ; 6. Variola varicel- 
loides ; 7. Febris variolosa sine erupfione. 

C. VARIOLA SEMICONFLUENS. 
The semiconfluent variety of small-pox is intermediate between 



VARIETIES. 483 

the distinct and the confluent, partaking sometimes of the mild- 
ness of the one, sometimes exhibiting many of the worst features 
of the other. It is difficult to offer any adequate explanation of 
these differences. Much depends on the constitution of the patient, 
something upon age, something too upon the condition of the 
mind. 



D. VARIOLA CORYMBOSA, OR COHERENT SMALL-POX. 

This term, as we have said, is applied to cases of partial conflu- 
ence, that is, to cases where the vesicles are grouped into clusters, 
leaving intermediate spaces of unoccupied skin. Most of these 
partake of the general character of confluent small-pox. It often 
happens, in this form of the disease, that the maturation is imper- 
fect. Instead of well-formed vesicles, blebs or bladders form, which 
fill with a thin semi-purulent fluid. Many of these cases run into 
secondary fever. Erythematous inflammation succeeds, probably 
in consequence of the imperfect concoction of the matter ; and ul- 
cers, followed by deep pits and eschars, are the unavoidable result. 
Much irregular fever accompanies the coherent small-pox. The 
cellular membrane is less extensively affected than in the thoroughly 
confluent variety. 

E. VARIOLA MALIGNA. 

The distinctive characters of this truly formidable variety of 
small-pox have been acknowledged in all ages. To the usual 
phenomena of the disease are superadded those which indicate a 
dissolved or putrescent state of the blood. This implication of the 
fluids of the body gives to the small-pox a character well desig- 
nated by the word malignant. The term petechial small-pox is 
equally appropriate. Trie evidences of malignity are perceptible 
in some cases from the first moment of febrile invasion. At other 
times they are perceived only when the eruption begins to de- 
velop itself. The initiatory fever is sometimes attended with 
petechia?, large patches of subcutaneous ecchymosis (called vibi- 
ces), or with hemorrhage from the nose, mouth, stomach, bowels, 
or uterus. The aspect of countenance is squalid, the urine dark- 
coloured, the breathing anxious, hurried, and irregular. Under 
these circumstances, death has taken place prior to any unequi- 
vocal appearances on the skin. That such a disease is unde- 
veloped small-pox must always remain a matter of some doubt ; 
but the fact can often be inferred from a careful investigation 
of the prior history. It will be found, for instance, that the 
patient had never previously undergone small-pox; that he 
had been exposed to small-pox infection within that reasonable 
limit of time which affords presumptive proof; or lastly, that he 
may himself, in turn, have communicated small-pox to others. 



484 N SMALL-POX. 

Many cases considered to be idiopathic malignant fever, proving 
fatal at an early stage, are in reality cases of undeveloped variola 
maligna. 

During the maturative stage, malignant small-pox is character- 
ized by the same kind of mucous and subcutaneous hemorrhages. 
The gums bleed, and often very profusely ; there are bleeding from 
the nose, spitting of blood, vomiting of blood, and the passage of 
blood by stool. Menorrhagia displays itself in females, and abor- 
tion scarcely ever fails to occur in such as are pregnant. The 
foetus dies in utero. As the disease advances to maturation, the 
vesicles fill, not with pus, but with a bloody ichor. Livid spots or 
petechia?- are interspersed among them. The eye is frequently the 
seat of extensive ecchymosis. This variety has been called the 
black pock [variolse nigrse). The malignant form of small-pox is 
generally found associated with confluence of eruption, both on the 
skin and mucous membranes. Sometimes, however, the eruption 
is of the semiconfluent or coherent kind, and, more rarely still, dis- 
tinct. Though delirium generally exists, it is yet by no means uncom- 
mon to find the mind perfectly clear throughout the whole course 
of petechial small-pox. This most aggravated state of the disease 
scarcely offers any reasonable ground of hope. Death usually 
takes place between the fifth and seventh days from the first ap- 
pearance of eruption, nature showing little or no disposition to for- 
ward the maturation of the pustules. We have seen death take 
place under these appalling circumstances, with the intellect quite 
unimpaired. 

F. VARIOLA ANOMALY. 

Under this head authors have arranged a variety of singular 
anomalies and rare complications. It were a vain and profitless 
task to enumerate them all, but some of the more common, and a 
few of the most rare, may advantageously be mentioned. Small- 
pox may occur to persons who, at the time of seizure, are labour- 
ing under some other malady, such as bronchitis, hooping-cough, 
pneumonia, phthisis, or other pulmonary disease. The compli- 
cation of small-pox with an acute or subacute form of bronchitis 
is very common during the winter months in this country, and it 
demands in almost all instances the treatment appropriate to the 
concurrent disorder. Small-pox may occur simultaneously with 
measles (De la Garde, Med. Chir. Trans., vol. xiii.), scarlet fever, 
and cow-pox. It may occur to persons of exceedingly weak habit 
of body, either constitutional or induced by long prior illness, such 
as a severe typhus fever. Under these and similar circumstances 
of extreme debility, we notice tardiness of eruption, collapse with- 
out advance of eruption, an abundant formation of large blebs, a 
tedious and hazardous period of convalescence. 

Among the anomalies of small-pox, we may enumerate its occur- 



VARIETIES. 485 

rence in the African negro, whose peculiar constitution of skin pre- 
vents the development of areola. 

Lastly, we may specify among the rarer occurrences the appear- 
ance of small-pox in the foetus at birth, showing that it must have 
imbibed the germ of the disorder, and gone through its earlier 
stages in utero. (Jenner, Med. Chir. Trans. , vol. i.) In the case 
recorded by Jenner, the mother experienced no indisposition her- 
self. Mead entertained the fanciful notion, that persons who 
showed in after life a complete insusceptibility to small-pox, might 
possibly have passed through the disease in the foetal state. (Mead 
on Small-pox, chap, iv.) 

G. VARIOLA CONFLUENS MITIGATA. 

A rare variety of small-pox was described by Van Swieten 
and others, under the title of Stone-pock, Horn-pock, and Wart- 
pock, ( Variola verrucosa, or cornea.) This is now very frequently 
observed, it being one of the many forms in which small-pox shows 
itself after vaccination. The initiatory symptoms are generally 
urgent. The eruption is abundant over the whole body, and often 
the aspect of the disease, for the lirst two or three days, is very 
unpromising. On the third or fourth day, however, a modification 
or mitigation of symptoms manifests itself. The vesicles shrivel, 
and a few only attain an imperfect maturation. The greater num- 
ber harden, and are converted on the sixth day into small tuber- 
cles, which gradually disappear. The febrile symptoms rapidly 
subside, and the patient, in less than a fortnight, is free from any 
perceptible complaint, except, perhaps, some weakness of the eyes. 
The absence of secondary fever is the great characteristic of this 
variety of small-pox. One of the peculiarities of the variola con- 
fluens mitigata, is the unequal advance made by the papulae on the 
same portion of the surface : on the face, or on the arm, for in- 
stance, pustules rapidly maturating, others of smaller size dying off, 
and some becoming tuberculated, with little or no surrounding in- 
flammation, may be perceived at one and the same time. This 
mitigated form of small-pox, now so common among the vaccinated, 
is still occasionally seen in persons who have never been vaccinated. 
Such mildness is attributable either to the general character of the 
epidemic, or to the idiosyncrasy of the individual. His system 
receives the small-pox in the first instance, perhaps, with alarm, 
but ultimately eliminates it with ease and safety. One of the re- 
markable effects of cow-pox is to create, artificially, a constitution 
thus favourably disposed towards small-pox. It multiplies the cases 
which our ancestors saw, and described under the name of variola 
verrucosa. 



486 



SMALL-POX. 



H. VARIOLA VARICELLOIDES. 

The umbilicated pustular Varicella of Rayer. 

This is the mildest form in which small-pox is ever seen. The 
initiatory symptoms are never urgent ; in some cases they escape 
observation. The eruption shows itself on the third day from the 
invasion of fever. This circumstance will afford useful aid in de- 
termining the character of the disease, and distinguishing it from 
varicella vera, with which it is so liable to be confounded. In the 
true varicella, the eruption shows itself, for the most part, without 
any prior symptoms, or, at least, within twenty-four hours from the 
occurrence of a slight febrile commotion. The diagnosis is com- 
pleted by observing the grouping of the papulae, and their construc- 
tion. When the disease is truly variola, the pimples never fail to 
show (either with or without the aid of the microscope), central 
depression. This great and undoubted criterion of variolous origin 
cannot be present, unless the morbid germ had lain dormant in the 
system during the long period necessary for such a development. 
A crop of vesicles may, indeed, be thrown out on the surface after 
a brief period of incubation ; but such vesicles are mere elevations 
of cuticle (minute blisters in fact), presenting no regular organiza- 
tion. Such is the pathological character of the genuine varicella, 
or chicken-pox. In some cases the resemblance between the vari- 
ola varicelloides and chicken-pox is so close, the febrile commo- 
tion so trifling, and the progress of the disorder so rapid, that doubts 
may reasonably exist as to the real nature of the complaint. None 
but those who are in the constant habit of seeing such cases, of 
tracing them to their source, and of observing the minute grada- 
tions by which nature connects the severe and mitigated forms of 
small-pox, could recognize, in a few scattered papulseover the face 
and arms, the same disease which in another form, bids defiance to 
every effort of human skill, and hurries its victim to a premature 
grave. This variety of small-pox, singularly mild as it is, was 
known to physicians before the time of Jenner. It is clear, from 
the perusal of Dr. Heberden's paper on chicken-pox, published 
in 1767, that such a complaint was well known to him; and that 
it gave occasion then, as now, to diagnostic doubts and difficulties. 
Since the discovery of vaccination, these cases of variola varicel- 
loides have multiplied prodigiously, and are now familiar to all. 



/. FEBRIS VARIOLOSA SINE ERUPTIONE. 

Sydenham entertained the opinion, that during years when 
small-pox was epidemic, a variolous fever was also to be met with, 
which showed no eruptions. He devotes a chapter (sect. hi. chap, 
iii.) expressly to the consideration of this disease. Our views re- 



DIAGNOSIS. 487 

garding the pathology of small-pox have undergone a material 
change since the time of Sydenham, and the notion is now gene- 
rally considered fanciful, but as it has received the sanction of some 
later writers (Btjrserius, Vogel, P. Frank, De Haen, Fouquet, 
Gatti, Hedlund), we may offer a few observations concerning it. 
The circumstances that induced Sydenham to connect a particular 
form of fever with small-pox, were the following : — 1. It appeared 
in years when small-pox was epidemic ; 2. It was ushered in by 
the same tenderness of the epigastrium which distinguishes inci- 
pient variola ; 3. It was accompanied by petechias, sal'vation, pro- 
fuse spontaneous sweats affording no relief, and other symptoms 
observable in a regular small-pox ; 4. It was benefited by the same 
cooling system of treatment. M. Hedlund of Hernoesand, during 
the Swedish epidemic of 1824, states (Magendie, Journ. de Phy- 
siologies torn, vi.), that three different forms of disease were then 
observed, all, as he believes, pathologically allied, viz., true small- 
pox, the varioloid, and a fever without eruption. This fever, he 
adds, began and ended at the same time with the epidemic. The 
early symptoms were identical with those which preceded the 
variolous eruption. He considered it as a mild undeveloped small- 
pox. The numbers attacked with this eruptionless fever, consti- 
tuted the third part of the whole number attacked during the epi- 
demic. " Perhaps," says M. Hedlund, "small-pox has the power 
of engendering an epidemical constitution, which influences other 
maladies reigning at the same period." Some authors of less note 
have even fancied that such variolous fevers have given subsequent 
immunity from small-pox. We have met with cases which bear out 
the notion of a mild variolous fever without developed eruption ; and 
as the identity of a highly modified varioloid fever with true small- 
pox is admitted, so would it be wrong to discountenance entirely 
the notion oi&febris variolosa sine eruptione. 



II. DIAGNOSIS. 

Before the appearance of eruption, the diagnosis of small-pox is 
always liable to uncertainty, even with every attention to the cha- 
racter of the prevailing epidemic, for the precursory symptoms are 
common to other diseases. The grounds on which we attempt, at 
this early period, to determine the nature of the approaching dis- 
order, are, 1. The suddenness of the attack; 2. The absence of pre- 
vious ailment ; 3. The exposure to variolous contagion ; and, 4. The 
having previously undergone one or more of the exanthemata, 
The diseases with which, after the occurrence of febrile eruption, 
small-pox may be confounded, are measles, febrile lichen, varicella, 
and secondary syphilis. 

1. The papula? of true small-pox are firmer than those of measles. 
They feel granular, like hard bodies, under the finger. In measles 



488 SMALL-POX. 

too there are accompanying cough, and watering of the eyes. Fur- 
ther, forty-eight hours elapse in small-pox from rigor to eruption ; 
seventy-two hours in measles. 2. Febrile lichen is the disease from 
which small-pox, at the onset of eruption, is with most difficulty 
distinguished. The aspect of eruption is in both cases nearly alike. 
The surest and safest grounds of diagnosis are based on the interval 
which has elapsed from rigor to eruption, and the seat and extent 
of eruption. In febrile lichen twenty-four hours elapsed from sick- 
ening to eruption ; in small-pox, as we have said, forty-eight. 
Small-pox almost always appears first on the face ; the eruption of 
lichen is equally developed, from the first, on the trunk and head. 
3. The diagnosis of small-pox and chicken-pox has been already 
pointed out. 4. There is a form of secondary syphilis, in which an 
eruption appears on the face and trunk very similar to distinct 
small-pox. This eruption passes through the several grades of 
papula, vesicle, and pustule. It is preceded by a febrile attack of 
variable duration. The circumstance has in many instances given 
rise to the notion of small-pox occurring twice. A case of this kind 
fell under our own observation very recently. The diagnosis is to 
be effected by accurate inquiry into the prior history of the case, 
and the further progress of the eruption. The pustular syphilitic 
eruption runs a tedious course, exceeding ten days ; and the pustules 
are developed, not simultaneously as in small-pox, but in succes- 
sive crops. 



III. PROGNOSIS. 

The danger in small-pox is dependent on a variety of circum- 
stances, but chiefly on the following: — 1, on the quantity of the 
eruption ; 2, on the condition of the mucous membrane ; 3, on the 
state of the fluids ; 4, on the state of the nervous system ; 5, on the 
age of the patient ; 6, on his habit of body ; 7, on the circumstances 
in which he is placed, and the treatment adopted. 

1. Distinct small-pox is a disease of little or no danger. Con- 
fluence is always unfavourable, especially on the face ; nor is the 
nature of the danger always understood. A confluent case shall 
sometimes appear to progress favourably, when unexpectedly a 
convulsive fit occurs, and the patient is destroyed. The drain which 
confluence necessarily occasions in the system is sometimes the ob- 
vious cause of danger. Nevertheless, if the pustules on the extremi- 
ties acuminate well, and are surrounded by a crimson areola, a 
good ground of hope exists. If the vesicles on the trunk and ex- 
tremities, on the other hand, be flat, with a clarety areola, while the 
eruption on the face is white and pasty, no reasonable hope of re- 
covery can be entertained. 

2. The condition of the mucous membranes, especially that of the 
larynx, is equally important with reference to prognosis. Hoarse- 



PROGNOSIS. 489 

ness at an early period of the disease is always unfavourable. A 
natural tone of voice, again, is a good omen, even though the erup- 
tion be full and confluent, with a disposition to cellular inflamma- 
tion. The appearance of the mouth and throat will also serve as a 
useful guide to the probable state of the larynx and trachea. 

3. The condition of the fluids is a circumstance by which the 
physician will in a great degree be guided in his prognosis. Every- 
thing which indicates malignancy and putrescency is highly unfa- 
vourable. Petechia, menorrhagia, mucous hemorrhages, and vesicles 
filled with a bloody ichor, are therefore among the worst signs that 
can occur. Recovery from the petechial small-pox has been re- 
corded, but it is among the rarest events which the history of this 
disease presents. 

4. A tranquil state of the brain and nervous system is particularly 
favourable, and is the circumstance to which the recovery of all 
severe confluent cases is mainly attributable. Quiet nights, compo- 
sure of manner, a contented disposition, and confident hope of re- 
covery, are good signs ; restlessness, on the other hand, a continual 
moaning, despondency of mind, and a succession of sleepless nights, 
afford bat little hope of recovery. Children who grind their teeth 
seldom do well. 

5. Age is a point of great moment in estimating the comparative 
degree of danger in confluent and semiconfluent cases; the ex- 
tremes of life are those on which small-pox always falls the heaviest. 
Persons above forty years of age seldom recover even from semi- 
confluent small-pox ; infants are in danger even from a moderate 
quantity of eruption ; in both the process of cicatrization is attended 
with great exhaustion of nervous power, the result of which is, 
that some internal organ necessary to life (the larynx, brain, or 
lungs), takes on acute and rapidly destructive inflammation. The 
arteries here act without the due control of the nerves. The most 
favourable age for taking small-pox is from the seventh to the four- 
teenth year, when the powers of life are in full vigour, without the 
risk of plethora. 

6. The habit of body is, of course, also to be taken into account. 
Small-pox is always aggravated by its concurrence with a pletho- 
ric habit. Great constitutional debility is equally to be dreaded. 
In the strumous habit the sequelae of small-pox are peculiarly 
severe, and often bring life into danger after the crisis has been 
passed. 

7. The probability of recovery must depend, lastly, upon the 
circumstances under which the patient is placed ; on the possibility 
of applying remedial measures effectively ; on the treatment which 
has been pursued in the early stages, and other contingencies which 
scarcely admit of enumeration. In hospitals the danger of con- 
tracting fever and erysipelas during the later stages is never to 
be lost sight of. In private life, small rooms, superabundant bed- 



490 



SMALL-POX. 



clothes and ill-timed cordials may aggravate or bring on local 
congestions and inflammations, from which the hospital patient is 
exempted. In certain seasons and states of the air, small-pox is 
more to be dreaded than at other times. 

These principles of prognosis will lead naturally to the consider- 
ation of the average mortality in small-pox, the usual sources of 
death, and the morbid appearances. 



IV. MORTALITY. 

The average mortality by small-pox is usually stated as one in 
four of those attacked, or twenty-five per cent. At the Small-pox 
Hospital the extremes have been fifteen per cent, and forty-two per 
cent. The average of twenty-five years prior to the introduction 
of vaccination gave thirty-two per cent. The proportion which 
the mortality by small-pox bears to the total mortality in any town 
or district, has been a favourite subject of inquiry with all writers 
on medical statistics. Prior to 1800, that is, before the period when 
vaccination influenced the results, the deaths by small-pox were to 
the total deaths, both in town and country, as 16 to 100. It was 
observed by all writers, that in the unprotected the greatest mor- 
tality takes place in the early periods of human life. Dr. Hay- 
garth computed that at Chester, in the latter part of the last 
century, one-half of the deaths in children below ten years of age 
was due to small-pox. The mortality is heaviest from the second 
to the fifth year. From the first Report of the Registrar-General 
of England, it appears that in 1837 there were only five diseases 
more fatal in England than small-pox, and that the deaths through- 
out England and Wales by that disorder amount now annually to 
about 12,000. 

Small-pox may prove fatal at any period from the first invasion 
of fever to the fortieth day. Death may even take place prior to 
the development of eruption ; but such cases are rare. In all 
countries it has been observed that the eighth is the day of greatest 
danger, and the second week that which exhibits the greatest 
amount of mortality. The annexed table, extracted from the 
records of the Small-pox Hospital for 1828-9, showing the period 
of eruption at which 168 patients died, and the days on which the 
disease proved fatal, illustrates this, while it points out how little 
importance can be attached to the doctrine of critical days in small- 
pox. 



MORTALITY. 



491 



Of 168 fatal cases of small-pox, there died on the 






' Days. 
3d 
4th 
5th 
6th 
7th 



Cases. 

1 

5 

10 

5 

11 

32 



' Days. 

8th 
9th 
10th 
11th 
12th 
13th 
14th 



Cases. 
27 
15 
14 
16 
11 
11 
5 

99 



Days. 

15th 
16th 
17th 
18th 
19th 
20th 



Cases. 
7 
5 
3 
3 
1 
2 

21 





'Days. 


Cases 




22d 


- 3 


J-H 


23d 


- 1 


K3 


24th 


- 3 


r ^j 


25th 


1 


cc3 


27th 


- l 


M 


28th 


- l 


© 


29th 


- 1 




31st 


- 1 


•B 


32d 


1 




35th 


1 




[ 38th 


- 2 



16 

The mortality varies, of course, with the character of the erup- 
tion. The subjoined table shows the proportion in which each 
variety of small-pox proved fatal at the Small-pox Hospital during 
the epidemic of 1838. 

Table exhibiting the comparative Mortality in the several varieties of Normal and 
Abnormal Small-pox at the Small-pox Hospital^ during the epidemic of 1838. 



Normal Small-pox. 
Confluent, 
Semiconfiuent, 
Distinct, - 

Total Normal, 

Abnormal Small-pox. 
Confluent modified, - 
Semiconfluent modified, 
Varicelloid, 

Total Abnormal, - 

Grand total, 


Unprotected. 


Vaccinated. 


Admitted. 

295 

78 

19 


Died. 

149 
8 



Admitted. 
56 
42 
20 


Died. 

21 

4 




392 


157* 


118 


25 


2 
1 
1 







38 

28 

114 


4 
1 
1 


4 





180 


6 


396 


157 


298 


31f 



The following table will complete this branch of the subject by 
pointing out the comparative mortality of small-pox at different 
ages, distinguishing the vaccinated from the unvaccinated. 



* Of these there died of fever and superadded erysipelas, 14. 
t Of these there died of fever and superadded disease, 10. 



492 



SMALL-POX. 



Table exhibiting the Mortality of Small-pox at different ages and under different 
circumstances , as displayed at the Small-pox Hospital of London, in the epidemic of 
1838. 



Ages. 


Unvaccinated. 


Vaccinated. 


Under 5 years of age, 
From 5 to 9 inclusive, 
" 10 to 14 « 
" 15 to 19 « 
" 20 to 24 " 
" 25 to 30 « 
" 31 to 35 « 
Above 35 years of age, 

Total, 


Admitted. 

42 

37 

30 
104 
115 

45 

12 

11 


Died. 

20 

11 

8 

32 

50 

23 

7 

6 


Admitted. 



5 

25 

90 

106 

55 

13 

4 


Died. 



6 
16 
8 
1 



396 


157 


298 


31 



The immediate causes of death in small-pox are various, as the 
preceding detail of symptoms will have shown, but it may be use- 
ful to exhibit them in a condensed form : 1. Prior to the maturation 
of the pustules (that is, from the invasion of fever to the seventh 
day of eruption), small-pox proves fatal by that general derange- 
ment of the system which occurs in malignant fever. Such a 
condition of the body is well designated by the term acute malig- 
nancy. 2. During the second week of eruption, the chief cause of 
death is to be found in affections of the larynx and trachea, and 
consequent suffocation. 3. During the third week, that is, during 
the stage of secondary fever, death may happen either by general 
excitement leading to effusion in the brain, or by supervening pleu- 
risy, pneumonia or laryngitis ; or, lastly, by extensive sloughy or 
gangrenous destruction of the skin. 4. During the fourth week, 
and at still later periods of the disease, death may take place from 
mere exhaustion, or it may be the result of erysipelas, or of some 
other disease excited by the small-pox, or engendered by that con- 
stitutional debility which such a disorder in any of its severer forms 
so frequently leaves. 



[V. STATE OF THE BLOOD. 

The blood was analyzed by Andral and Gavarret in 5 cases 
of true variola and 2 of varioloid disease. In all the cases of variola 
the eruption was confluent. The blood-corpuscles differed but 
little from their normal standard, but the quantity of fibrin varied 
considerably, although the increase above the normal mean was 
only small. It is worthy of remark, that the quantity of fibrin ap- 
pears to increase, although only slightly, by repeated bleeding ; a 
circumstance which, according to Andral and Gavarret, cha- 



ANATOMICAL CHARACTERS. 493 

racterizes the phlogoses. This may be due to the inflammatory 
state of the skin in this disease, although we do not perceive a 
similar occurrence in typhoid fever, in which the mucous surface of 
the intestine is in a somewhat similar state. 
Their analyses gave the following results : 



Venesection 




Water. 


Fibrin. 


Blood- corpuscles. 


Residue of serum. 


I 


>1 


771-5 


4.4 


120-6 


103-5 


1st Case < 


2 


780-8 


2-9 


110-2 


106-1 


1 


1-3 


820-2 


3-2 


94-6 


82-0 




fl 


791-3 


30 


114-3 


91-4 


2d" j 


|2 


803-9 


3-2 


92-6 


100-3 


i 3 


811-8 


30 


88-4 


96-8 


1 


U 


817-3 


3-3 


87-0 


92-4 


3d" 


[1 


781.4 


2-6 


127-9 


88-1 


! 2 


792-0 


3-5 


124-4 


80-1 


4th" 


[ 1 


796-0 


4-1 


126-5 


76-4 


1 2 


792-7 


2-0 


124-9 


80-4 


5th « 


1 


805-0 


2-9 


98-8 


92-3 



The residue of the serum contained on an average 7-0£ of inor- 
ganic constituents. 

In the first case, the first bleeding was ordered at the commence- 
ment of the disease, during the febrile period ; the second at the 
commencement, and the third at about the middle of the eruptive 
stage. In the second case, the first bleeding was ordered some 
days before the appearance of the disease ; the second during the 
fever ; the third on the third day of the eruption, and the fourth on 
the sixteenth day of the eruption. In the third case, the first bleed- 
ing was ordered at the commencement of the eruption ; the second 
during the suppurative stage. In the fourth case, both venesections 
were prescribed during the height of the eruption. In the fifth 
case the pustules were filled with blood (variole hemorrhagique :) 
the bleeding was ordered when the eruption was at its height. 

The analyses of blood in varioloid gave the following results : 



Water. 


Fibrin. 


Blood-corpuscles. 


Residue of serum. 


785-6 


2-3 


120-3 


91-8 


782-1 


2-4 


125-8 


89-7 



The residue of the serum contained 7-6f of inorganic matter in 
the second analysis. 

In the first instance the bleeding was performed on the 3d day; 
and in the second case on the 2d day of the eruption.*] 



VI. ANATOMICAL CHARACTERS. 



Small-pox offers the only instance of a constitutional disorder 
which has for the immediate cause of death the condition of the 
surface. Extensive burns and scalds afford, in the practice of the 

* [Simons' Animal Chemistry, p. 244.] 



494 SMALL-POX. 

surgeon, abundant opportunities of witnessing the excessive con- 
stitutional disturbance occasioned by the destruction of large por- 
tions of skin, and death so brought about. The physician sees it 
only in the case of small-pox. In many instances, the state of the 
surface is the sole cause of death. In others, the disorganization 
of the mucous tissues has gone on pari passu with the superficial 
injuries. In a third set of cases, serious lesions of internal parts are 
observed, but many of these are the mere consequences of the cuta- 
neous disorganization, and of the impediments to transpiration 
thereby occasioned. 

The condition of the surface after death by confluent small-pox 
has been described with considerable accuracy by many authors, 
but by no one has the subject been so minutely examined as by Dr. 
Petzhold of Leipzig, who derived his experience from an epidemic 
which prevailed in that town in the winter of 1832-33.* It is by 
examination of the skin after death, that modern pathologists have 
obtained that insight into the structure of the variolous pock, and 
the changes produced on the several parts of the cutaneous tissue 
in the further advance of the disease, which have been already 
noticed. The base of each pock presents, in almost all instances 
(except in the palm of the hand and sole of the foot), a small de- 
pression or aperture, formed by the rupture of the excretory duct of 
a cutaneous gland. The portion of cutis not occupied with pocks is 
loaded with a white puriform matter, which, as in the case of the 
pustules, wedges itself in between the bundles of vessels. At an 
early period of disease, the undermost layers of the epidermis are 
in a softened state. At a later period, its connection with the cutis 
is altogether destroyed. The cutaneous glands are always more 
or less swollen, so as to assume a pyriform shape, and their excre- 
tory ducts are frequently much distended by the secretion of the 
glands, which are always found more vascular than in their healthy 
state. The epithelium of the tongue and mouth is much softened. 
The subjacent mucous membrane frequently exhibits erosions vary- 
ing in depth. The mucous follicles of the tongue and tonsils are 
observed to be greatly distended, and their mouths to gape so 
widely as to admit readily the entrance of a large probe. 

The appearances of the most importance are those presented by 
the mucous surface of the larynx and trachea. In all severe cases 
implicating those structures (provided death takes place prior to the 
twelfth day), the marks of destructive inflammation in them will be 
apparent ; that is to say, the membrane appears deeply congested 
with blood, and covered with a copious viscid purulent or puriform 
secretion of a gray or brownish colour. On detaching this, the mem- 
brane itself appears thickened, pulpy, and in the worst cases black 
or sloughy. A closer examination of the parts affords the following 

* Die Pocken-krankheit mit Racksicht auf die Pathologische Anatomie. Leip- 
sig, 1836. A copious analysis of this work, in as far as relates to the morbid ana- 
tomy of small-pox, may be found in the Brit, and For. Med. Rev., vol. v. 



ANATOMICAL CHARACTERS. 495 

appearances. The surface of the epithelium exhibits, in an early 
stage of the disease, a number of dim spots of a round form, and of 
the size of lentils, produced by the exudation of a fluid between the 
epithelium and the subjacent mucous membrane. In the further 
advance of the disease, this effusion becoming more copious raises 
the epithelium, which may then be stripped off, exposing the in- 
flamed and sometimes ulcerated mucous membrane. The diseased 
appearances of the trachea are not always uniformly diffused over 
the whole surface, though the epithelium is easily separable even 
from the unaffected parts. The ulcerations vary both in number 
and depth, extending sometimes to the submucous cellular texture. 
Disorganization of the bronchial mucous membrane may be traced 
into the third series of branches. 

The oesophagus has been found in some instances to be studded 
with minute elevations, which have been described as pocks. This 
appearance is very rare. The lungs exhibit, in some cases, the usual 
evidences of inflammatory action, viz., vascular engorgement, puru- 
lent infiltration, and hepatization; but the chief appearances within 
the chest are those presented by the serous membrane. The pleura 
of one side (rarely, if ever, of both sides) is found to exhibit the 
marks of recent and perhaps of very intense inflammatory action. 
It appears highly injected with blood, and covered with a thick 
layer of coagulable lymph, while in the corresponding cavity of the 
chest there is abundance of sero-purulent fluid, resembling cream 
and water, with shreds of lymph floating in it. In many cases, so 
copious is the inflammatory exudations, as to fill completely one side 
of the chest, and to compress the lung of that side into a very small 
space. [Lobar pneumonia is much more common than lobular, 
the reverse of that which takes place in measles. Serous conges- 
tion is the marked characteristic of variolous pneumonia. " It is 
astonishing," observe Rilliet and Barthez, " to see the quantity 
of sanguinolent serosity which the slightest pressure forces from 
the inflamed parts. This serous congestion often extends over 
the entire lung, even when there is little or no pneumonia — con- 
stituting true pulmonary oedema."] 

In the cranium the morbid phenomena observable in small-pox 
present no features of peculiar interest.^ In persons cut off by con- 
vulsion or coma r the same appearances may be found as under like 
circumstances where no affection of the surface is present. A gene- 
ral vascularity of the brain and its enveloping membranes will pro- 
bably present itself, with some effusion of turbid serum between 
the membranes, or in the ventricles, or in the theca vertebralis. 

Much difference of opinion has prevailed regarding the abdo- 
minal appearances met with in those who die of small-pox. Sir 
Gilbert Blane has recorded a case wherein the mucous membrane 
of the bowels is reported to have been occupied with small round 
ulcerated spots. Many pathologists have expressed their belief that 
true variolous pustules have been found in the gastro-enteric mucous 



496 SMALL-POX. 

membrane. Others, again, among whom may be mentioned Cotun- 
nius Wrisberg, and Reil, (who have paid great attention to the 
subject,) are of opinion that this structure is incapable of developing 
variolous pustules, and that the appearances so described are in 
reality inflamed, enlarged, or ulcerated follicles, with petechial 
patches, similar in all respects to what are found in the common 
forms of idiopathic or typhoid fever. This pathological principle is 
fully borne out by the experience of the Small-pox Hospital. We 
may add, however, that even these appearances are very rare, and 
that the freedom of the abdominal viscera from urgent symptoms 
during life, and from all trace of disorganization after death, is a 
remarkable feature in the disorder. Inflammation may, indeed, 
originate from accidental causes in any internal organ during the 
progress of small-pox, and its effects will be seen after death ; but 
these are not to be confounded with the specific and acknowledged 
effects of the variolous poison upon the skin and mucous membranes 
of the throat and chest. [MM. Rilliet and Barthez describe 
the follicular eruption as consisting of small hemispherical projec- 
tions, either pointed or slightly flattened, with often a small central 
black point, which is sometimes depressed. On pricking these pro- 
jections, after carefully drying them, a little drop of serous fluid 
escapes. All this encourages the belief of their variolous or vesicu- 
lar character, but this is discountenanced, from the following facts: 
1. Identical sero.us projections exist in other diseases, and are there- 
fore not peculiar to variola. 2. A variolous vesicle cannot be formed 
where no epithelium exists. 3. Rilliet and Barthez have never 
seen in the intestines those small false membranes, or other lesions, 
resembling those found on the other mucous membranes, as the 
mouth, pharynx, or larynx. The anal orifice is the only point of 
the intestinal mucous membrane, upon which variolous pustules are 
found. 4. Another proof exists in the condition of the agminate 
follicles, which are often as much developed as the isolated. They 
are large, projecting, softened, and often reddened, simulate the 
patches in typhoid fever at their commencement, and differ from 
them only in not presenting any ulcerations. Rilliet and Barthez 
affirm that they have never met with, and believe it is very rare 
to find, enlargement, redness, or softening of the mesenteric glands. 
The intestinal mucous membrane frequently exhibits traces of an- 
terior congestion — being covered with a layer of thick and adhe- 
sive mucus ; or presents a general iron-gray colour, with occasional 
dark punctations. The same authors assert that most of the organs 
exhibit more or less intense sanguineous congestion : — the muscles 
are red and firm ; the membranes and the substance of the brain 
much injected ; and the sinuses gorged with blood. On dividing 
the pulmonary vessels blood flows abundantly; and the liver, spleen, 
and kidneys are in the same condition. But exceptions to this rule 
are met with, and several times, when the eruption was pale, little 
or no injection was observed in the various organs after death. 



causes. 497 

MM. Rilliet and Bakthez have very generally observed the 
blood, especially in the cavities of the heart and large vessels, fluid 
and serous, and sometimes of the colour of wine lees. If there are 
clots they are small, black, and diffluent ; it is rare to find them 
colourless and fibrinous.] 



VII. CAUSES. 

The phenomena of small-pox being thus described, we proceed 
to investigate its causes, to unfold what is known regarding its 
mode of origin and propagation, and the circumstances under which 
it most commonly displays itself. The notions entertained on this 
subject at the present time differ most materially from those which 
prevailed at an earlier era of the world, and are perhaps still sus- 
ceptible of improvement. For more than a thousand years after 
the first appearance of small-pox, it was believed by all physicians 
to originate like other fevers ; that is to say, either from some viti- 
ated state of the fluids of the human body, or from some peculiar 
state of the atmosphere. To this day a large portion of mankind 
believe that small-pox may be bred in the blood, independent of all 
external agency. Boerhaave adopted the notion that small-pox 
was in all cases the product of a specific poison, miasm, or conta- 
gion derived from some one already labouring under the malady. 
This opinion strengthened during the latter part of the last century, 
until at length Dr. Haygarth, Dr. Jenner, and others promul- 
gated the notion, that by a system of quarantine and other measures 
of precaution, the small-pox might be utterly banished from the 
earth. The latter opinion is now acknowledged to be doubtful in 
theory and utterly visionary in practice; but a belief that small-pox 
is in all cases the result of a contagion received from without, is 
adopted by all the best pathologists and practical physicians of the 
present day. It wouid certainly be difficult to support the doctrine 
of spontaneous origin by arguments which would be generally re- 
ceived : but while we admit the hypothesis of contagious origin, we 
must not shut our eyes to the importance of the facts which connect 
small-pox with other epidemic maladies, such as the Egyptian 
plague, malignant cholera, influenza, and hooping-cough, where 
the notion of contagious origin is only partially admitted. To un- 
derstand the origin and propagation of small-pox, therefore, it 
must be viewed not only as a contagious, but as an epidemic 
disorder. 

1. Contagious origin of Small-pox. — The contagion of small- 
pox emanates from the human body at every period of the disease, 
from the first invasion of fever to the throwing off of the latest 
scabs. Heberden and Haygarth affirmed, that during the ini- 
tiatory fever, and for the two or three succeeding days, a patient 
32 



498 SMALL-POX. 

seldom, if ever, communicated the infection. But this is incorrect. 
The dry scabs of small-pox retain the contagious property for a 
great length of time. Experience, too, has shown, that for a con- 
siderable time after death the matter of the pustules continues 
energetic, and that a confluent case will taint the air and spread the 
disease for at least ten or twelve days after death. (Hawkins, Lond. 
Med. Gaz., vol. iii.) Nothing is better ascertained regarding the 
contagion of small-pox, than the fact, that the kind of disorder pro- 
duced bears no certain relation to the kind or intensity of the case 
producing it. A confluent case shall give origin to a varioloid, and 
a mild distinct case shall generate a confluent and malignant one. 
The circumstances that determine severity in any individual case, 
whether of small-pox or of any other exanthema, are very little 
known to us. The following is only an imperfect attempt to illus- 
trate this problem in the history of small-pox. 

The quantity of eruption is sensibly influenced by the state of the 
surface at the period of its development. Whatever 'tends to aug- 
ment the cuticular circulation, increases confluence, such as the 
warm bath, abundant bed-clothes, strong diaphoretic and sudorific 
medicines, wine and cordials, and great heat of the apartment. All 
local irritants, such as blisters, mercural inunction, and plasters, 
favour confluence in parts to which they have been applied. Cold 
represses the number of papulae, though not so certainly as heat 
favours them. Active purgatives taken during the incubative stage 
lessen the extent of cutaneous inflammation. A plethoric state of 
body increases the intensity of the disorder, and is mainly instru- 
mental in occasioning cellular complication. An irritable condition 
of the nervous system gives occasion to that conjoined affection of 
the brain and nerves which authors have called Variola nervosa. 
Extreme weakness of body appears often to be the direct cause of 
that dissolved state of the fluids which we call acute malignancy; 
but not always, for malignancy, as Huxham well observed, is com- 
patible with plethora. Lastly, it may be remarked that there exists 
in certain individuals, and not unfrequently in many members of 
the same family, a peculiar irritability under the influence of the 
variolous contagion. They receive it with alarm, they develop it 
with pain, and get rid of it with difficulty. Such constitutions may 
truly be said to be poisoned by it. Again, other persons imbibe 
the morbid germ mildly, nourish it without suffering, and eliminate 
it safely and kindly. All this is referable to idiosyncrasy. 

The variolous contagion is capable of attaching itself to fomites, 
more especially bed-furniture, clothes, and bedding. These, if 
closely wrapped" up and secluded from the air, will retain the 
matter of the disease and give it out to others at great distances of 
time. But free exposure to the air greatly diminishes or alto- 
gether destroys this infecting property ; for the contagion of small- 
pox is of a very volatile nature. The medical attendant, therefore, 
who goes into the open air after visiting a small-pox patient, seldom 



causes. 499 

if ever communicates the disease. Experiments were made in 1832 
for the purpose of determining the power which chlorine possesses 
to destroy the contagion of small-pox, and likewise the effects of a 
very high temperature in disinfecting bedding and clothes, but the 
results were unsatisfactory. 

The peculiar miasm or morbid germ of small-pox is given off 
both by the skin and the lungs/ It possesses a peculiar odour. It 
may be received into the human body in three ways. 1. It may 
be diffused through the air, and enter the system through the me- 
dium of the lungs. This is called the mode of infection. 2. The 
matter of the pustules, or a scab, may be applied to the unbroken 
surface of the skin, or to the mucous membrane of the nose, and be 
thus absorbed. This is strictly called the mode of contagion ; but 
it must be admitted that the terms contagion and infection are often 
used indiscriminately to express the silent, or, as we say, casual 
reception of the germ. Lastly, small-pox may be taken by apply- 
ing the fluid matter to a wound of the cutis, and thus causing its 
certain absorption. This is called the mode of inoculation, of 
which we shall treat at large hereafter. 

2. The epidemic origin of Small-pox. — The facts which prima 
facie suggest the notion of an atmospheric origin, and which, at any 
rate, serve to associate small-pox with the large tribe of epidemic 
disorders, are the following : — 

Small-pox, at particular times, spreads with extraordinary facility 
over a certain district of country. Its ravages, in these epidemic 
visitations, increases for a certain length of time, attain their crisis 
or height, and then gradually recede. Attempts have been made 
to fix the periods of epidemic visitation, and while some have 
stated seven, others have named fourteen years as the most com- 
mon interval. The greatest epidemic years experienced by the 
present generation in England, have been 1781, 1796, 1825, and 
183S. The intervals here have been fifteen, twenty-nine, and 
thirteen years, but on various intermediate occasions small-pox has 
prevailed, though with less intensity. On the last occasion, the 
epidemic began in London in November, 1837, reached its height 
in June, 1838, and finally ceased in January, 1839. A course 
nearly similar was observed in each of the three preceding years 
of extensively epidemic small-pox. It has been attempted to con- 
nect the occurrence of small-pox on such occasions with some 
unusual condition of the atmosphere, but in vain. Nothing pecu- 
liar has been observed, either with regard to the heat or dryness of 
the seasons, or the state of the winds, in those years. Neither the 
thermometer nor barometer helps to explain the phenomenon. 
Small-pox sometimes spreads in a fine clear atmosphere, sometimes 
in a cold and moist state of the air. The frosts of winter and the 
heat of summer are alike congenial to it. It is not an unreasonable 
supposition, that the phenomenon may depend on some peculiarity 



500 SMALL-POX. 

in the electrical condition of the air, which science may hereafter 
detect. It is known that, in epidemic years, not only is small-pox 
more general, but it is of a more aggravated character, and conse- 
quently more fatal. There are grounds for supposing that at such 
times the sphere of contagious influence is much widened. Dr. 
Haygarth, who took great pains to investigate this matter, believed 
that the distance to which the contagious effluvium extends beyond 
the person of the individual affected, was )n all cases alike, and 
always very limited, not exceeding a few feet. There is reason to 
suspect, however, some fallacy in these observations. It is very 
difficult, undoubtedly, to determine with accuracy the distance at 
which the poison ceases to be energetic, but it is almost certain that 
the constitution of the air, in epidemic year& permits a very wide 
diffusion of the variolous germ. It is supposed by some that this 
diffusibility is the very essence of that principle which we designate 
as the epidemic constitution of the atmosphere. But this cannot 
be all ; for it is often noticed that persons (vaccinated persons, for 
instance) who resist small-pox in common years, though fully ex- 
posed to the contagion, are attacked by it in years of epidemic 
prevalence. These and other facts, which bear on the epidemic 
origin and diffusion of small-pox, were overlooked by those san- 
guine pathologists, who imagined that in vaccination Nature had 
provided us with means adequate for the complete extermination 
of small-pox from the earth. 

Susceptibility of Small-pox. — Ail mankind, with few excep- 
tions, are born with a susceptibility of small-pox. This suscepti- 
bility, unless altered by vaccination, remains, for the most part, 
equally strong at all ages; though sometimes, from accidental 
causes, a particular individual shall take it at one period of life, and 
resist it at another. Persons have been known to go through a 
long life, exposed frequently to the contagion of small-pox, and yet 
never take it casually. The same persons have received the 
disease by inoculation at an advanced age. A lady was success- 
fully inoculated for small-pox at Salisbury, in 1804, when eighty- 
three years of age. She had brought up a large family. A few 
persons pass through life apparently insensible to the variolous 
virus, whether exposed to it casually or by the mode of inocula- 
tion. These cases, however, are exceedingly rare. The power that 
vaccination possesses to lessen this susceptibility, and to protract 
the period of receptivity, or, in the opinion of some, to destroy the 
susceptibility of small-pox in the human frame altogether during 
the whole subsequent term of life, is a subject which will be dis- 
cussed in a future page. An immunity from small-pox is said to 
be a peculiarity in some families, but there is little foundation for 
such a notion. The circumstances which (independent of vaccina- 
tion) render a person, either through life, or at particular periods 
of life, unsusceptible of small-pox, are not well known. Some- 



CAUSES. 501 

thing may depend on the state of the recipient, something on the 
equality or intensity of the effluvium. 

Recurrent Small-pox. — In the greater part of mankind, one 
attack of small-pox gives immunity from future attacks. The 
virus, indeed, may again have access to the body, but neither fever 
is excited, nor any kind or degree of constitutional disturbance. 
Exceptions to this law have undoubtedly occurred. In all ages, 
from the time of Rhazes, who first described small-pox, its recur- 
rence has been recorded ; and of late years, from particular circum- 
stances affecting the alleged power of vaccination, these cases have 
been brought prominently forward. It will be necessary, therefore, 
to inquire somewhat more accurately into the phenomena of recur- 
rent small-pox. 

The rarity of such cases may be inferred from the fact, that no 
instances are recorded of persons being received twice into the 
Small-pox Hospital; and the instances of alleged secondary small- 
pox, admitted into that institution, have been very few. Some 
physicians of the last century could with difficulty be persuaded 
that such cases ever occurred. Heberden estimated them at only 
1 in 10,000; other writers, at 1 in 8000, or 1 in 50,000. 

Sir Gilbert Blane (Select Dissertations) remarks, " that all 
the well-authenticated cases of second small-pox have been of per- 
sons who in the first instance had it severely." This would seem 
to connect the recurrence of small-pox with some peculiar prone- 
ness in the system to suffer under the variolous virus. Such a 
constitution is said to show a variolous diathesis. Other patholo- 
gists, again, have noticed that where second attacks have occurred, 
the first have been very mild. They have imagined, therefore, that 
the first attack was not in sufficient intensity to alter the whole 
mass of blood, or, in other words, absorb and destroy variolous 
susceptibility. It has been stated, that cases of inoculated small- 
pox are more likely to be followed by second attacks, than where 
the disease is received casually : but Baron Dimsdale, whose ex- 
perience was great, denied the correctness of this statement. 

Some cases have been recorded where the first attack had been 
in such intensity as to leave undisputed evidence of itself in the 
form of pits and scars, and it has even been said that occurring 
under such circumstances, a second attack has proved fatal. The 
interval between the two attacks is usually very long, extending 
to twenty or thirty years. In almost all cases, the two attacks vary 
in intensity ; where the first attack was severe, the second proves 
of the mild, horny, or verrucous kind. On the other hand, where 
the first is light and varioloid, the second is comparatively severe. 
It ought not, however, to be forgotten, in forming an impartial esti- 
mate of the frequency of such occurrences, that many sources of 
error are to be taken into account. The attacks succeed each other 
at long intervals, and the real nature of the first attack is not always 



502 SMALL-POX. 

easily ascertained. There are, too, as we have already shown, 
many diseases which resemble variola (such as lichen, varicella, 
porrigo, secondary syphilis), and a mistake may be made in truly 
designating the secondary as well as the primary attack. Without 
meaning to throw discredit on some of the recorded cases of double 
sma!i-pox, we may, therefore, be permitted to doubt the correctness 
of others ; and, at all events, it must be conceded that unequivocal 
cases of recurrent small-pox are rare. They have been, and will 
continue to be, objects of curiosity to the practical physician. We 
shall hereafter have occasion to recur to these doctrines, and to 
show that the attempts made to explain the occurrence of small- 
pox after vaccination, upon the same pathological principles as 
apply to recurrent small-pox, have totally failed. 

It happens occasionally that a local effect is produced by the 
application of variolous matter to the body after it has fully un- 
dergone small-pox. Thus nurses who suckle children with small- 
pox, frequently exhibit small-pox pustules on the breast, and 
sometimes feverishness supervenes. Surgeons have unguardedly 
pricked their finger with the point of a lancet armed with vario- 
lous matter, and have suffered in consequence ; but in these cases 
the affection is local, and the accompanying fever purely symp- 
tomatic. 

All the cases which have been recorded of small-pox occurring 
a third or a fourth time in the same person may be set down as 
apocryphal. 



VIII. TREATMENT. 

The labour that has been bestowed in delineating the several 
varieties and modifications of small-pox, and in explaining the 
circumstances under which it shows itself, has been vain and profit- 
less, if medicine be of no service in ameliorating the condition of 
the patient, and lessening the rate of mortality. Nevertheless it 
must be borne in mind, that the influence of medical treatment is 
much less manifest in this than in many other acute diseases. Im- 
proper treatment may, indeed, aggravate the danger, but it often 
happens that the most skillful treatment scarcely lessens it. It is a 
melancholy reflection, that for many hundred years the interference 
of the physician, often thwarting but seldom aiding the efforts of 
nature, was calculated to diminish rather than to increase the 
chance of the patient's recovery. Before entering on the curative 
treatment of small-pox, therefore, it will be proper to recall to re- 
membrance the peculiar nature of the disorder. It is a fever which 
relieves itself by superficial eruption. That eruption, even when 
too copious, cannot be diminished or checked in its progress by any 
efforts of art ; when moderate, it requires not the interference of the 
physician. His efforts should be confined, 1, to moderating the 



TREATMENT. 503 

arterial excitement when too abundant ; 2, to supporting the vis 
vitae where it obviously flags ; 3, to the relief of urgent and oppres- 
sive symptoms, which may incidentally arise in any of the three 
stages of invasion, maturation, and decline. Heroic remedies are 
here wholly inapplicable, and the great object of art is simply to 
place the system under the most favourable circumstances for 
effecting what the old physicians called the concoction and elimi- 
nation of the morbid humour. An historical survey of the me- 
thods of treatment pursued in small-pox, presents a succession of 
measures, which it is the boast of modern medicine to have 
abandoned. The hot regimen, bleeding, opiates, stimulants, blis- 
ters, and unguents, have been in various ages of the world brought 
forward as means of undoubted power in the cure of small-pox. 
The object of the physician in modern times has less of pomp, but 
more of true philosophy about it. He is content if he can keep 
within due bounds the action on the surface ; if he can check 
the congestions and inflammations which occasionally supervene 
in internal parts; and, lastly, if he can support the system under 
protracted fever, and the exhaustion consequent on extensive pus- 
tulation. 

1. The initiatory stage. When the nature of the approach- 
ing disorder is unknown, the treatment must necessarily be adapted 
to the character of the symptoms present. Where it is suspected 
to be small-pox, the following rules apply. The antiphlogistic 
regimen is to be pursued as far as the case admits. The surface is 
to be kept moderately cool. Where pain of the epigastrium, or of 
the back, or of the head, is very urgent, blood may be taken from 
the arm, the amount being regulated by the fullness and force of 
the pulse. Leeches applied to the temples afford great relief to 
the headache, where the general character of the circulation for- 
bids general blood-letting. A brisk cathartic, composed of three 
or four grains of the chloride of mercury with eight of the com- 
pound extract of colocynth may be advantageously given to mode- 
rate the tumult of the general system. Saline draughts in a state 
of effervescence may be taken frequently, and the addition of a 
pill containing two or three grains of James's powder serves to 
direct the fluids to the surface. Coldness of the extremities will 
be met by hot bottles to the feet, the pediluvium, or mustard poul- 
tices. A languid circulation requires the aid of stimulants, such 
as camphor julep with ether, wine, or brandy and water. Great 
restlessness must be quieted by an opiate conjoined with antimonial 
wine. 

It has often been said that blood-letting, in the fever of invasion, 
interrupts the process of nature, retards or altogether repels the 
eruption, and so weakens the system as to prevent the due matu- 
ration of the pustules. On the other hand, some writers have 
maintained that free blood-letting, -at this stage of small-pox, is the 



504 



SMALL-POX. 



only measure which can effectually lessen confluence, and prevent 
the development of pustules on the mucous expansion of the 
mouth and throat. Both these opinions have been taken up in igno- 
rance of the real value of blood-letting at this stage of small-pox, 
and of the mode of its operation. Blood-letting has no influence 
on the quantity of eruption, whether cutaneous or mucous. Again, 
while it sometimes, when incautiously practised, retards the erup- 
tion, it as often hastens and encourages it. The eruptive process 
is frequently impeded by the violence of the febrile commotion, 
and the oppressed state of the great internal organs, the brain, the 
heart, and the lungs. Whenever these organs are gorged, and 
their functions interrupted by a load of stagnant or inflamed blood ; 
where intense headache, extreme irritability of stomach, oppressed 
breathing, and a full labouring pulse give evidence of such general 
or local congestion, the loss of blood proves the safest and the 
surest diaphoretic. To bleed, however, merely because small- 
pox is anticipated, with the view of preventing confluence, is use- 
lessly to waste that power which will be required for the repair 
of extensive injury to the surface. The physician will carefully 
consider all the circumstances of the case, and, keeping these gene- 
ral principles in view, endeavour to promote eruption and diminish 
internal congestion, without materially impairing constitutional 
power. 

2. The matukative stage. — While the pustules are in process of 
maturation, a variety of measures may be pursued, which, without 
interfering with the salutary and necessary process of pustulation, 
lessen the patient's suffering, and prevent subsequent difficulties. 

When the eruption .comes out tardily, with continuance of sick- 
ness and vomiting, the pulse being small and thready, mustard poul- 
tices or a blister may be applied to the epigastrium, and hot bottles 
put to the feet. The bowels should be relieved by stimulating in- 
jections, and the stomach quieted by small doses of an opiate 
repeated at short intervals. When the patient complains of great 
pain in the throat, with difficulty of swallowing, leeches may be 
put on the throat, and the bleeding encouraged by fomentations of 
poppy-heads and camomile flowers. When the surface is very ten- 
der and painful to the touch, cooling lotions may be applied ; and 
in distressing cases, a few leeches will be found the only effectual 
means of diminishing the local inflammation on which the symptom 
depends. 

The condition of the internal organs will require constant super- 
intendence and regulation during the whole period of maturation, 
more especially in all cases possessing, or approaching to the cha- 
racter of confluence or semi-confluence. When the pulse is sharp, 
and the skin hot and dry, purgative medicines must be administered 
daily. They may consist of senna and salts, or the compound pow- 
der of jalap, or castor oil, or of calomel and colocynth, or calomel 



TREATMENT. 505 

and jalap, according to the urgency of the symptoms, and the pecu- 
liar habits of the patient. The action of the kidneys is to be en- 
couraged by frequent doses of the citrate of potash in effervescence, 
or of the liquor ammonia? acetatis, or of any similar mild diuretic. 
When cough and copious expectoration of mucous or muco-purulent 
matter, with increasing dyspnoea, give evidence that the lungs, or 
smaller ramifications of the bronchia, are taking on inflammatory 
action, blood must be taken from the arm to the extent of fourteen 
ounces, and full doses of antimonial wine with mucilage added to 
the saline draught. When headache, a flushed face, redness of the 
eyes, and strong beating of the carotid and temporal arteries accom- 
pany a state of delirium, it will be requisite to draw blood from 
the arm, to apply leeches to the temples, and purge the bowels freely 
by calomel and jalap. The mere occurrence of delirium in small- 
pox is not, however, per se, an adequate ground for blood-letting. 
Delirium is often present when the pulse is small, and the conjunc- 
tiva shows no increased vascularity. Delirium of this kind will abate 
as the cutaneous inflammation advances to its crisis. Great care 
should, however, here be taken to protect the patient from self-in- 
jury. 

In this, and, indeed, in all cases of small-pox of the least severity, 
it will be proper, from the very first period at which the disorder 
becomes manifest, to direct the hair to be cut close, and so main- 
tained throughout the whole course of the disease, and for several 
weeks afterwards. The head is thus kept cool ; delirium is relieved, 
or prevented ; the danger of cellular inflammation of the scalp di- 
minished ; the chance of ophthalmia lessened ; cleanliness enforced. 
For such great advantages, the finest head of hair should be sacri- 
ficed. Ophthalmia occurring during the maturative stage is to be 
combated by leeches to the temples, an active purgative of calomel 
and jalap, and the local treatment recommended under Variolous 
Ophthalmia. In all cases it is desirable that the patient should be 
kept in a darkened chamber. His room should be large and airy. 
His diet should consist of milk and bread, arrow-root, oranges, ripe 
fruits, and roasted apples. His drink may consist of toast and water, 
milk and water, whey, tamarind-water, apple-tea, and lemonade. 
Sydenham's favourite beverage at this stage of the disease was 
small-beer, which may safely be allowed. 

When the irritation on the surface is very great, and the nights 
are restless, an opiate may be given with great advantage at bed- 
time. It may consist of thirty drops of laudanum, or ten grains of 
Dover's powder. An aperient draught the following morning 
should not be omitted. 

When small-pox is associated with that train of symptoms which 
constitutes acute malignancy (or a dissolved and putrescent state of 
the fluids), the influence of medicine is scarcely to be recognized. 
Acids are usually administered mixed with the decoction and tinc- 
ture of bark, with a view to augment the crasis or coagulating 



506 SMALL-POX. ' 

power of the blood. Ether, camphor, port-wine, brandy, and other 
stimulants are to be given in quantities proportioned to the wants 
of the system. Astringents are of no avail. Much attention has 
been paid in all ages to the local treatment of the pustules. The 
practice of puncturing the pustules, and draining off their contents, 
was begun by the Arabians, and has been often recommended since, 
on the plea that danger was to be apprehended from the absorption 
of matter, This opinion, however, is founded on a pathological 
error, and the practice is now abandoned by those who test its effi- 
cacy on a large scale. 

The French have more recently introduced the plan of cauterizing 
the vesicles in an early state, so as to prevent their subsequent de- 
velopment. In the corymbose form of small-pox, where a cluster 
of vesicles has formed near the eye, some benefit may be derived 
from the adoption of this remedy ; but it is inapplicable to a case of 
universally confluent small-pox, and it is unnecessary in the milder 
varieties of the disorder. Some recent observers state that mercurial 
plasters, composed either of calomel or of corrosive muriate, have 
the power, when applied to the skin, of so modifying its condition, 
as to prevent the maturation of the pustules. Applications com- 
posed of calomel, however, possess no such power. Those com- 
posed of corrosive sublimate occasion great irritation, and convert a 
mass of confluent vesicles into one large and painful blister, but it 
would be unreasonable to expect benefit from such a change. The 
practice has therefore been silently abandoned. 

[The ectrotic, or abortive method of treating the eruption by cau- 
terization of the individual pustules, recommended by Breton- 
neau, Serres, and Velpeau, is available only when the eruption 
is discrete, and from its difficulty and the pain it produces, it should 
be*confined to those parts where it is important to prevent cicatrices. 
Practised on the first or second day of the eruption it instantly ar- 
rests its further progress, and, according to MM. Rilliet and Bar- 
thez, frequently succeeds when delayed to the third, fourth, or even 
fifth day. "The inflammation," observe those authors, "as well as 
the pustules, is cut short, at least this effect has invariably followed 
cauterization of the pustules on the margins of the eyelids. It is 
almost incredible how rapidly the oedema of these parts disappear." 
Zimmermann, Rosen, and others, had remarked the influence which 
mercurial plasters exerted in arresting the progress of the vario- 
lous pustule. The fact, however, seemed to be forgotten, until Dr. 
Serres, and afterwards Drs. Briquet and Nonat, called the at- 
tention of the profession in France to the favourable results of the 
experiments which they had made with mercurial applications in 
the treatment of small-pox. According to Dr. Briquet, whose 
memoir* is the most complete yet published on the subject, if the 

* [Archives Generates de Medecine, Octobre, 1838.] 



TREATMENT. 507 

face or other parts of the body are covered with mercurial plaster, 
during the first, second, or not later than the third day, suppuration 
is arrested, and the resolution of many of the pustules is effected: the 
others are converted into vesicles or tubercles. The mercurial plas- 
ter of the French Codex, or Emplastrum de Vigo cum Mer curio* 
spread upon some coarse stuff, stiff enough to support itself, is the 
application recommended and employed, whilst a little mercurial 
ointment is applied to the eyelids and nostrils, the plaster not being 
readily kept on these parts. It is allowed to remain three days in 
simple small-pox, and a day longer in the confluent variety. MM. 
Rilliet and Barthez, to meet the difficulty of maintaining the 
due application of the plaster in children, use the following cerate 
as a substitute. — Mercurial ointment, 24 parts; — yellow wax, 10 
parts ; — black pitch, 6 parts. M. Professor Wood states that he 
has used the mercurial ointment of the United States Pharmacopoeia, 
with success in a very bad case of small-pox. t Dr. GoblinJ states 
that during a recent epidemic at Stains, he observed great benefit 
from the use of mercurial ointment, in arresting the progress of the 
pustule, and removing surrounding inflammation. He used it 
stronger and more frequently in proportion as the eruption had a 
tendency to become more confluent: its use was continued for seve- 
ral days. Dr. Stewardson, who tried the practice in the Phila- 
delphia Small-Pox Hospital, states that he feels satisfied, " from the 
experiments there made, that the mercurial plaster exerts a decided 
influence upon the pustules, preventing more or less their perfect 
maturation, and diminishing the concomitant inflammation, swell- 
ing, and soreness. I did not find that it prevented pitting altogether, 
but only that it lessened the liability to it. Independently, however, 
of its influence in this respect, the application of the mercurial plas- 
ter to the face, is valuable in some cases, with the view of moderat- 
ing the inflammation, as the patient is thus relieved of considerable 
swelling and pain, as well as from the inconvenience arising from 
the formation of thick scabs. The strong mercurial ointment was 
used in some cases, whilst in others it was rubbed down with an 
equal bulk of lard. It was spread upon a piece of thick muslin 
shaped like a mask, and then carefully applied to the forehead and 
face."§ The plasters should not be allowed to remain on after the 
fourth day, as softening of the base of the vesicles may ensue and 
cicatrices be formed. Slight erysipelas has been occasionally ob- 
served, and a limited eczema is more frequently produced, but it 
soon passes off and is of little consequence. That the power of 
promoting the maturation resides in the mercury is evident from 

* [United States Dispensatory, 5th ed., p. 916.] 
f [Ibid.] 

t [Revue Medicale, Juin, 1845.] 

§ [American Journal of Medical Sciences, January, 1843, and Elliotson's Prac- 
tice of Medicine, Am. Ed. p. 438.] 



508 SMALL-POX. 

the fact that plasters of lead had no effect in changing the nature of 
the eruption, and the pustules were developed as freely under ad- 
hesive plaster as upon the free surface of the skin. Larrey, on 
his return from Egypt, recommended the application of gold leaf, 
previously smeared with gum Arabic mucilage. Some experiments 
performed in New Orleans by Dr. Picton would prove that the 
exclusion of light is an effectual means to prevent pitting. A 
number of patients were placed in a dark ward of the hospital 
during the eruptive stage of the disease, and though some of them 
had the disease violently and of the confluent form, no deformity of 
the skin was observable. The tincture of iodine repeatedly applied 
to the pustules, at an early period, has been recommended by Dr. 
Samuel Jackson, of this city, and formerly of Northumberland.] 

3. The secondary Fever. — The decline of the mild forms of 
small-pox requires little else than attention to the state of the bowels, 
and care lest a too great indulgence of the appetite should engender 
feverish excitement. A warm bath is advisable before the patient is 
permitted to mix again with the world. 

Where secondary fever sets in with any of those complications 
formerly described, the means of relief must be adapted to the 
peculiar circumstances of each case. The rules applicable to the 
treatment of fever generally apply here, but the following principles 
may be kept in view. 

When the pustulation is profuse over the whole body, the strength 
of the system is to be supported by nourishing diet, an allowance of 
ale and porter, and gently cordial medicines. These cases usually 
end favourably, though the exhaustion may be great, and the con- 
valescence very tedious. On the other hand, when the skin dries 
up, and fever rages in the mass of blood, the greatest attention is 
required to prevent local congestions, or to check them when they 
arise. The patient is to be kept upon a low diet, saline medicines 
are to be diligently administered during the day, a purgative draught 
is to be directed every morning, and the first appearance of local 
disorder is to be met by its appropriate treatment. A very absurd 
dread of purgative medicines in both the maturative and secondary 
stages of small-pox has influenced the minds of many practical 
physicians. It is difficult to imagine how it could have arisen, for 
the value of purgatives is fully as manifest in small-pox as in any 
other acute disease. 

The period of secondary fever is often accompanied with symp- 
toms of extreme debility. The pulse is scarcely to be felt. The 
tongue is covered with a dark fur. The skin is cold. The expres- 
sion of countenance is truly typhoid. Subsultus tendinum, and 
general tremors, further indicate the great exhaustion of nervous 
power. The most powerful stimulants are now demanded. Wine 
must be administered liberally, and the medicine should be com- 
posed of ether, the subcarbonate of ammonia, and an aromatic 
tincture in camphor julep. 



TREATMENT. 509 

Erysipelas succeeding small-pox must be treated simply with 
reference to the accompanying state of the circulation. Sometimes 
it is best combated by purgatives and saline diaphoretics ; at other 
times wine and tonics are obviously indicated. Variolous oph- 
thalmia is, of all the various sequela? of small-pox, the most difficult 
to manage. The loss of blood which the intensity of the symptoms 
appears to warrant would speedily be followed by great and per- 
haps irremediable exhaustion. Leeches, cupping-glasses to the 
temples, calomel and opium, active aperients, and warm fomenta- 
tions, afford a better prospect of eventual benefit. In some cases, 
the eye must be sacrificed to save the patient's life. Variolous 
pleurisy demands the loss of blood from the arm, the application of 
warm fomentations to the side, and a steady perseverance in the 
use of that powerful diaphoretic, which is presented in the combi- 
nation of calomel, James's powder and opium. 

The management of the pustules in the stage of desiccation and 
decline has been as much an object of attention as their treatment 
in an earlier period. When the pustulation is profuse, it is very 
requisite to apply liberally some simple dry powder to absorb the 
discharge ; hair powder, starch powder, the powder of calamine, 
and well-dried flour, are alike available for this purpose. Cold 
cream and mild unguents (such as the ung. cetacei, with a propor- 
tion of oxide of bismuth) are useful when there is much cutaneous 
irritation with a dry surface. The efforts so frequently made in 
former times to prevent pitting, by means of masks and divers 
ointments, ended generally in disappointment. The only means 
which can be relied on for preventing such disfigurement, are those 
which allay general cutaneous excitement. Purgative medicines 
and low diet, therefore, are those which best deserve our confidence. 

When small-pox has called into activity the scrofulous diathesis, 
the utmost efforts of the physician will be required, but often with 
very indifferent success. A course of sarsaparilla is sometimes 
beneficial. Occasionally, moderate doses of mercury (in the form 
of blue pill, or of the hydrargyrum cum creta) will improve the 
secretions, and with them the general health. But the remedy of 
most unquestionable efficacy is change of air ; it imparts tone to the 
languid cutaneous vessels, converts an ecthymatous surface into 
healthy granulations, improves the appetite, and diminishes the 
strumous irritability of the retina. The influence of an altered air 
on the diseased actions of the body is better displayed in the se- 
quelae of small-pox than in any other known disorder. 



510 SMALL-POX. 



VARIOLOUS INOCULATION. 

The universality, severity, and mortality of small-pox have been 
such as to stimulate the minds of men to the discovery of means 
whereby the ravages of this frightful disease might be in some mea- 
sure controlled. Two measures have been devised for this purpose. 
The one was invented about the beginning of the eighteenth cen- 
tury, in Turkey ; this is Variolous Inoculation. The other was dis- 
covered in England towards the close of the same century by Dr. 
Jenner ; this is Vaccination. Both discoveries are wonderful efforts 
of the human mind, unfolding the secret but beneficent provisions 
of Nature for the mitigation of her most baneful pestilence. 

We shall begin with inoculation ; tracing first its origin and sub- 
sequent diffusion, then describing the mode of conducting the pro- 
cess, and concluding with some reflections on its value. 

I. HISTORY. 

It is an extraordinary circumstance, that the ingenious inventor 
of this mode of mitigating small-pox should be unknown. It has 
been conjectured that it had its origin in the Turkish provinces 
bordering on the Black Sea (Circassia and Georgia), and that it was 
first adopted for the purpose of securing the beauty of female slaves ; 
but this opinion is not borne out by any adequate authority. It is 
rather believed to have been first practised in the Morea. Still less 
reliance can be placed on the statements put forth as to the antiquity 
of this practice in China and Hindostan. All that we know for 
certain is, that the first accounts of inoculation came from Constan- 
tinople, and there, towards the close of the seventeenth or com- 
mencement of the eighteenth century, small-pox inoculation must 
be considered to have originated. 

In the year 1703, rumours of the great success attending this new 
operation reached the ears of Dr. Emanuel Timoni, a Greek phy- 
sician, who, after studying and graduating at Oxford, had settled 
as a physician in Constantinople. Convinced, by considerable ex- 
perience, of the importance of the discovery, Dr. Timoni, in 1713, 
communicated the facts to Dr. Woodward, by whom they were in 
turn communicated to the Royal Society of London in 1714. In 
1715, Mr. Kennedy, an English surgeon, who had traveled in 
Turkey, published an account of the new mode of inoculating 
small-pox, in his Essay on External Remedies. In the same year 
Dr. James Pylarini, the Venetian consul at Smyrna, published 
the accounts which had reached him of this novel practice. A 
notice of his work appeared in the Philosophical Transactions 
for 1716. These curious and important facts were, however, alto- 
gether overlooked by the British physicians of those days, and 



HISTORY. 511 

might have been still longer neglected, but for the talent and 
energy of a lady, the celebrated Lady Mary Wortley Montague, 
wife of the English ambassador at Constantinople. Her spirited 
and often quoted letter (Letters of Lady M. W. Montague, vol. 
ii.), dated April 1, 1717, thus describes the new process: — 

"The small-pox, so general and so fatal amongst us, is here 
entirely harmless by the invention of ingrafting, which is the term 
they give it. There is a set of old women who make it their busi- 
ness to perform the operation every autumn in the month of Sep- 
tember. Every year thousands undergo this operation ; and the 
French ambassador says pleasantly, that they take the small-pox 
here by way of diversion, as they take the waters in other coun- 
tries. There is no example of any one who has died in it ; and 
you may believe I am well satisfied of the safety of this experi- 
ment, since I intend to try it on my dear little son. I am patriot 
enough to take pains to bring this useful invention into fashion in 
England." 

The introduction of inoculation into England proved, however, 
a more difficult task than Lady Mary had expected. Nothing 
short of the spirit and enterprise of such a woman could have suc- 
ceeded in overcoming the prejudices which prevailed equally in 
the public and the medical profession at that time. On the return 
of Lady Mary to London, in April, 1721, her daughter was inocu- 
lated, the first example of inoculation in England. The experi- 
ment was then tried on six condemned criminals in Newgate. 
( JVoodville's History of Inoculation.) These and some other 
trials being deemed satisfactory, the Princess of Wales consented 
that her daughters, the Princesses Amelia and Caroline, should be 
submitted to the process, the former being then eleven, and the 
latter nine years of age. Their inoculation took place on the 19th 
of April, 1722. They both passed through the disease in a very 
favourable manner; but the new practice, commenced under such 
brilliant auspices, received a severe check immediately afterwards, 
in the death of the Hon. W. Spencer, son of Lord Sunderland, and 
in that of the butler of Lord Bathurst, both of whom were inocu- 
lated in April, 1722. 

In June, 1721, inoculation commenced in America, under the 
direction of Dr. Boylston of Boston. Between that period and 
the end of January, 1722, 244 persons were inoculated by him, of 
whom six died. The subjects, however, were ill chosen, and the 
operator displayed as much ignorance as rashness. The news of 
this disaster reached London at the very time when the public 
mind was agitated by deaths in two of the noble families of Eng- 
land, occasioned by the new practice ; and it is not surprising that, 
under such circumstances, inoculation should have been generally 
discountenanced. In fact, so little progress did it make, that be- 
tween 1721 and 1729, the total numbers inoculated were only 897, 



512 SMALL- POX. * 

of whom 845 went through true small-pox, 13 exhibited an imper- 
fect effect, in 39 the operation failed altogether, and 17 died. 

In other countries, the new practice found more favour than in 
England ; and when, in 1738, these facts became known, its repu- 
tation in this country was gradually restored. It was not, however, 
till the middle of the century, that the practice of inoculation was 
at all general. Several circumstances contributed at that period to 
give a favourable bias to the public mind. In 1746, the Small-pox 
and Inoculation Hospital was founded, for the avowed purpose of 
extending to the poor benefits which had hitherto been exclusively 
confined to the rich. In 1747, Dr. Mead, then the most popular 
of the London physicians, published his work Be Variolis et Mor- 
billis, and devoted a chapter to the recommendation of inoculation. 
In 1754, the Royal College of Physicians of London sanctioned 
the practice by an official document; and in 1755, the excellent 
Memoir on Inoculation, by M. de la Condamine, (first published 
in Paris in 1754,) appeared in an English dress. 

A new era in the history of inoculation commences with the 
introduction and general adoption of the Suttonian practice in 
1763. Robert and Daniel Sutton were sons of Mr. Robert 
Sutton, surgeon, of Debenham in Suffolk, who had acquired 
some fame as a successful inoculator. Both sons followed their 
father's profession. The one established himself at Bury St. Ed- 
munds, the other at Ingatestone in Essex. Both were in repute, 
but the success of Daniel at Ingatestone was surprising. It was a 
success fairly earned by the boldness and dexterity of his manage- 
ment. The following appear to have been the chief merits of the 
Suttonian system of inoculation. 1. The tedious preparatory pro- 
cess advised by his predecessors was curtailed from a month to a 
week. 2. He prepared the system by a course of antimonial and 
mercurial purgatives. 3. He inoculated by a single puncture, in- 
stead of the numerous incisions and clumsy modes of introducing 
the virus which had been in use before his day. 4. He had great 
tact in the selection of good lymph for inoculation. 5. He exposed 
his patients freely to the coldest air, both prior to and during the 
progress of the inoculation. 6. He inculcated the necessity of a 
spare diet and cooling drinks. The merit of the Suttons was dis- 
paraged because there was nothing new in all this. The Turkish 
children, it was said, were allowed to continue at play. Syden- 
ham had taught the value of the cooling regimen. The Americans 
had employed a mercurial purgative. This, however, does not 
take off from the merit of Daniel Sutton, whose clear and com- 
prehensive mind selected what was good, and rejected the faulty 
parts of his predecessors' practice. 

Baron Dimsdale succeeded to the popularity and extensive 
practice of the Suttons. In 1766, he published the first edition of 
his valuable work, ( The present Method of Inoculating for the 
Small-pox,) containing all the essential parts of the Suttonian plan, 



INOCULATION. 513 

avowedly taken from the practice of Daniel Sutton, together 
with the results of his own experience. This work passed through 
six editions, and became the standard book on inoculation. No 
further improvements took place. The confidence of the public in 
the safety and efficiency of inoculation augmented annually;' and 
in the year 1798, all the upper rariks of society in this country, 
and a considerable proportion of the lower, received the small-pox 
hi this way. In June, 1798, Dr. Jenner announced the discovery 
of vaccination. In two years afterwards the general practice of 
inoculation declined. In 1-808, it had almost gone out of use, and 
has never since been revived. 



II. PRACTICE OF INOCULATION. 

Inoculation is performed by introducing into the arm, near the 
insertion of the deltoid muscle, by means of a lancet, a minute por- 
tion of thin or crude variolous lymph. Well-digested purulent 
matter may also be employed. One incision is sufficient. On the 
second day the wound, under the microscope, presents the appear- 
ance of a minute orange-coloured spot. On the third or. fourth 
day, the patient experiences the sensation of pricking in the part; 
the punctured point is hard, and a minute vesicle, with central 
depression, may be observed, surmounting an inflamed base. On 
the fifth day the vesicle is well developed. On the sixth day the 
patient feels stiffness in the axilla, with pain. The fnoculated part 
has become a hard and inflamed phlegmon. The subjacent cellular 
membrane is involved in the inflammatory action. On the evening 
of the seventh, or early in the eighth day, rigors, headache, vomit- 
ing, offensive breath, alternate heats and chills, languor, lassitude, 
and perhaps in a child an epileptic paroxysm, announce the setting 
in of fever. The constitution has taken alarm, and sympathizes 
with the progress of the local disorder. 

After the appearance of febrile symptoms the inflammation of 
the arm spreads rapidly. An areola of irregular shape develops 
itself, in which minute confluent vesicles may be traced. The 
areola continues to advance till the tenth or eleventh day, when the 
arm is hard, tense, shining and very red. The pustule discharges 
copiously. On the eighth or ninth day, spots of variolous eruption 
show themselves in various, and often in the most distant, parts of 
the body. The eruption is generally distinct, and moderate in 
quantity. The papulae can generally be counted without difficulty. 
One hundred or two hundred are considered a very full crop. Occa- 
sionally not more than two or three papulae can be discovered, 
which sometimes shrivel and dry up without going through the 
regular process of maturation. At other times, the eruption is full, 
and semiconfluent, passing through all the stages of maturation, 
pustulation, and cicatrization, as perfect as in the casual disease. 
Between these extremes, every possible variety may be observed. 
33 



514 



SMALL-POX. 



The true confluent eruption with cellular complication is, however, 
rare. Still rarer is the affection of the mucous membranes ; and 
that implication of the fluids, which constitutes a malignant small- 
pox, is scarcely ever observed to succeed inoculation. Secondary 
fever, therefore, and its consequences, are very seldom met with. 

It often happens that on the eighth or ninth day prior to the erup- 
tion of the genuine variolous papulae, the body is overspread with 
a rose-coloured efflorescence [Roseola ex anthem atica of authors). 
In a day or two, distinct papules may be detected amidst the general 
redness. The rash then declines, and the papulae pursue their 
regular course. This variolous roseola is said to occur in about 
one case in fifteen of inoculated small-pox. It is the indication 
of a mild and favourably disposed eruption. It often precedes, in 
like manner, the mitigated form of small-pox, as it occurs casually, 
with or without preceding vaccination. 

The following rules and cautions for the safe performance of 
inoculation have been laid down by the best authors, especially 
Baron Dimsdale, and they come recommended to us, as well by 
their own reasonableness, as by the results of long and successful 
experience. 1. Inoculation should be performed exclusively in 
persons free from actual bodily disease, not plethoric, and, so far as 
possible, in persons of sound constitution, without tendency to scro- 
fula. 2. Inoculation may be safely practised at all ages, but some 
discrimination is of course necessary to insure a successful result. 
Infants may be- safely inoculated about the fourth month, before the 
process of dentition has actually commenced. Children are also in 
a fit state for inoculation from the second or third year of life to 
the period of puberty. Adults, whose blood is not inflamed by 
spirituous liquors or excessive exercise, may be safely inoculated. 
3. It is improper to inoculate during the period of pregnancy, partly 
from the condition of the maternal blood, but chiefly from the dan- 
ger of affecting the child. 4. Inoculation may be practised at all sea- 
sons, and in all climates. Baron Dimsdale noticed a greater abun- 
dance of pustules in spring, than at any other season of the year. 
It proved not less successful in the West Indies than in Russia. 5. 
Whatever tends directlyor indirectly to diminish plethora, to mode- 
rate arterial excitement, to lessen determination of blood to the 
skin, to clear the bowels of offensive sordes, to regulate the secre- 
tions generally throughout the body, and to preserve the blood in a 
cool and healthy condition, is useful in the conduct of inoculation. 
Perfect health being the best condition for receiving and safely 
eliminating small-pox, whatever tends to improve the health, in- 
creases the chances of eventual safety. Hence arises the necessity 
of preparing the body, in certain cases, by a mild diet, cathartic or 
gently laxative medicines, abstinence from all violent exercise, and 
all indulgence in heating of spirituous liquors. Hence, too, we 
may deduce the importance of cool chambers, light clothing, and 
sometimes free exposure to the external air, in the management 



INOCULATION. 515 

of inoculated small-pox. 6. The exhibition of antimonial and 
mercurial medicines, not for the purpose of regulating secretions, 
but with a view to produce a state of body especially favourable 
to the reception of small-pox, is a useless and idle ceremony. The 
Suttons made this part of their plan ; but Sir George Baker, Dr. 
George Fordyce, and, latterly, Baron DiMSDALE,saw the absurd- 
ity and quackish nature of the scheme, and denounced it as frivo- 
lous and vexatious. Preparation to persons in sound health is 
unnecessary, for a man cannot be better than well ; but while we 
disregard unmeaning ceremonies, let it not be forgotten that much 
caution is requisite when we form a judgment of the state of the 
blood and secretions (or humours) in any person, particularly in an 
adult. 7. Some differences of opinion exist as to the degree of 
importance to be attached to the selection of the lymph with which 
the inoculation is to be performed. Common sense would dictate 
the propriety of such precaution, and would suggest, as the fittest 
matter, such as is taken from a person of sound constitution, where 
the disorder is running its regular course, and it is of the mild or 
benignant kind. That these precautions have often been neglected 
with impunity, that severe cases have followed the use of carefully 
selected lymph, and vice versa, that mild cases have resulted from 
the insertion of matter from confluent pustules, is undoubted, and, 
therefore, too much stress should not be laid on the selection of mat- 
ter, but it is unreasonable to disregard it altogether. The Suttons 
preferred the crude or early lymph taken from a primary inoculated 
vesicle. It is agreed on all hands, that the lymphatic or crude 
matter of the fifth and sixth days is superior in efficacy and cer- 
tainty of effect to the purulent or well-concocted matter of the eighth 
and ninth days. 

Lastly, the treatment in inoculated small-pox must be guided 
by the same principles which have been laid down as applicable to 
the casual disease. A few doses of mild laxative medicine will 
be useful. The propriety of continuing a mild and unirritating 
diet is obvious. No local application should be made to the punc- 
ture, unless inflammation should run high. In that case, cooling 
lotions to the arm, and a purgative powder containing calomel and 
jalap, should be employed. 

III. VALUE OF INOCULATION. 

Since the discovery of vaccination, it has been the fashion to cry 
down inoculation, and to exaggerate its defects, An impartial 
estimate of the value of inoculation may not, therefore, be well 
received, but it ought not to be omitted. It was one of the early 
objections to inoculation, that no reasonable argument could be 
afforded why the inoculated should prove so much milder than the 
casual small-pox, why so much difference of effect should result 
from the morbid germ being received into the system, through the 



516 SMALL-POX. 

medium of the cutaneous absorbents. The circumstance is truly 
inexplicable, but it must not blind us to the facts. Much labour 
was bestowed by the statistical writers of the last century, in at- 
tempts to determine the average mortality of inoculated smail-pox. 
The professed inoculators, perhaps, concealed or explained away 
some cases. The prejudices of others exaggerated the number of 
unsuccessful results. It must never be forgotten, that persons may 
be inoculated after imbibing the germ of the disease casually, and 
thus death may be unfairly attributed to inoculation. Persons, too, 
may die of other diseases contracted during the process of inocula- 
tion. Making due allowances for these sources of error, it may be 
stated that where due attention is paid to the selection of subjects, 
and the careful management of the disorder, not more than one 
out of five hundred cases will terminate unfavourably. There can 
be no question but that the ill success which attended the early 
inoculations in England, arose entirely from bad management, from 
careless selection, ignorance of the principles by which the practice 
should be regulated, and the most absurd modes of surgical treat- 
ment. The improvement in the rate of mortality, so remarkable 
when the practice fell into the hands of judicious men like Sutton 
and Dimsdale, is decisive of this question, and gives some idea of 
what the practice might have been brought to, had it continued to 
the present day, profiting by the increased attention now given to 
matters of detail, and the generally improved pathology of modern 
times. 

It has of late years been much urged as an objection to inocula- 
tion, that small-pox was often taken casually after it, but this im- 
pression never prevailed during the period when inoculation was 
general. It may safely be said, that inoculation gave as complete 
and certain exemption from a second attack, as the casual disease 
itself. The two great objections to variolous inoculation are, 1. 
That it proves the exciting cause of other disorders, and more espe- 
cially that it calls into activity the scrofulous taint. This is an evil 
inherent in the very nature of the process ; but inasmuch as the 
inoculated is milder than the casual disease, by so much is the 
danger lessened, when that process is adopted. 

2. The second great objection against the practice of inoculation, 
insisted on by almost all writers since the discovery of vaccination, 
is, that it perpetuates the foci of contagion, multiplies the sphere of 
their operation, and thus, in protecting the life of one individual, 
exposes to imminent risk the lives of others, who, personally less 
careful, are not the less deserving of the public care and attention. 
The argument is very specious, and certainly important; but it 
should not be received without some inquiry. Such an objection 
to inoculation was brought prominently forward on various occa- 
sions during the last century, and especially in 1777. Dr. Watkin- 
son, Dr. Schwenke, and others, in that year, attempted to diminish 
its force, by pointing out how important a part epidemic influence 



INOCULATION. 517 

played in the diffusion of variola. They argued, that where such 
epidemic influence existed, the spread of small-pox would be 
equally great, whether inoculation were practised or not. On the 
other hand, when no such condition of the atmosphere prevailed, 
inoculation would be in this respect harmless. They may have 
overrated the value of this argument, but it must not be overlooked. 
The strongest proof of its force is, that in 1838, when inoculation 
was unknown in London, the admissions into the Small-pox Hos- 
pital exceeded those of 1781, when inoculation was universally 
practised; both being years of epidemic prevalence. Had inocu- 
lation been practised in London in 1838, its wider diffusion then 
would undoubtedly have been attributed to that source. Sir Gil- 
bert Blane (Med. Chir. Trans., vol. x.) has laboured diligently 
to prove this charge against inoculation by reference to the bills of 
mortality. He makes it appear that the proportion which the mor- 
tality by small-pox bore to the total mortality, increased during the 
last century from 78 in 1000 to 94 in 1000. From this he con- 
cludes, that "inoculation, by opening a new source for the dif- 
fusion of its virus, has actually been found to add to the general 
mortality of small-pox." A statement of this kind seems at first 
sight incontrovertible, but all arguments deduced from statistical 
researches must be received with limitations; and many circum- 
stances concur to show the necessity of this in the present instance. 
In the first place, as Sir G. Blane himself candidly acknowledges, 
the general mortality has diminished ; consequently, if the mortality 
by small-pox had remained stationary, the same result would have 
occurred. But, further, the population has vastly increased, and 
this must influence the result. Dr. Adams (Inquiry into the Laws 
of different Epidemic Diseases) has shown that a corresponding 
increase has taken place in other diseases not communicable by 
contagion. He further makes it evident, that, by a different mode 
of calculation, a diminution in the deaths by small-pox, since the 
more general adoption of inoculation, rather than an increase, may 
be made to appear. Thus, in the thirty years that elapsed between 
1741 and 1770, there died of small-pox within the bills of mortality, 
63,308 persons ; whereas, in the next thirty years, (viz., from 1771 
to 1S00 inclusive,) when inoculation was general throughout Lon- 
don, there died only 57,268. 

These considerations must convince any unprejudiced mind, that 
the argument against inoculation, drawn from its supposed tend- 
ency to augment and multiply the foci of contagion, is not so forci- 
ble as the opponents of inoculation invariably allege. 

On a general review of all the facts bearing on variolous inocu- 
lation, we cannot refuse to acknowledge, that it was a most valua- 
ble discovery, and the process itself a merciful provision of Nature 
against the ravages of a frightful pestilence. Had not the discovery 
of Jenner occurred to interrupt the extension of the practice, it 
would probably have continued to this day, increasing 3^early in 






N UVIN A no\ 



popularity, Whether it be ever destined again to occupy the 
thoughts of men, and tOCO-operatQ with vaccination in the general 
design of mitigating the severity of small-pox, is a question which, 
at the present time, it would be certainly premature, and perhaps 
unnecessary, to consider. 



\ UTINATION 

Tin- second measure which has been devised for controlling the 
severity and limiting the ravages of small-pox is vaccination, The 
circumstances that paved the way to this great discovery are fully 

known to us from various sources, of wlueli we must content our 
selves with offering a brief outline. 



I, BIS reuv. 

It is to the indefatigable leal of Dr. Jenner, that the world is 

indebted For the discovery of vaccination, lie appears very early 
in life to have had his attention fixed by a popular notion among 
the peasantry of Gloucestershire, of the existence of an affection 
in the cow, supposed to afford security against the small-pox ; but 
he was not successful in convincing his professional brethren of the 

importance of the idea ; and so distasteful did the subject of COW- 
pox become to litem, that he was at length compelled tO abandon 

all attempts to interest others in the inquiry. His own ardour, how- 
ever, was undiminished, and for nearly twenty years he continued 
Without interruption to follow his favourite pursuit. 

In the progress of his investigations, Jenner was impressed with 

the practicability of propagating the cow-pox by inoculation, from 
the eow first, and subsequently from one human being to another, 

so as to perpetuate the disorder. This magnificent idea appears to 
have first occurred to him about the year 1780, It was long after 

this date, that JENNER first attempted, by actual experiment, to 

prove the truth of his speculations. So slowly did the philosophical 

mind of JENNEB ripen into conviction, that be inoculated Ins own 
son with small-pox in November, ITS! 1 . It must be acknowledged, 
however, that opportunities of experiment were not easily found; 
the C0W-p0X was often absent from the dairy-farms lor many years 

iii succession. At length, however, the favourable opportunity 

occurred ; cow-pox in an active state was found, and on the 1 1th 

o\ May, 1796, (commonly regarded as the birthday of vaccination), 
a child eight years of age was vaccinated by Dr. Jenner, with 

matter taken from the hands o( a milker. He passed through the 
disorder in a manner perfectly satisfactory, and on the 1st of .Inly 



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the Variolm Vaccinae 

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520 VACCINATION. 

In 1799, the practice of vaccination commenced in America; and 
in the same year, the most eminent physicians and surgeons of Lon- 
don signed a strong testimonial of their confidence in the virtues of 
cow-pox. In 1800, vaccination was introduced into France, and 
spread rapidly over the whole continent. In 1802, it commenced 
in Hindostan, and was thence propagated over every part of the con- 
tinent of Asia. The parliament of England voted to Dr. Jenner 
30,000/. as a reward for his discovery, and his generous devotion 
to the public welfare. Dr. Jenner died in 1823, at Berkley, the 
scene of his early labours, full of years and honours. During the 
latter years of his life, he devoted much of his time to the subject 
of vaccination, but he never wrote much concerning it subsequently 
lo 1803. 

It is now necessary to advert to some of the circumstances which 
clouded the brilliant prospect with which vaccination began. In 
1809, Mr. Brown, of Musselburgh, published his opinion that the 
prophylactic virtue of cow-pox diminished~as the distance from the 
period of vaccination increased, but his statements made no impres- 
sion on the public mind. In 1818 and 18-19, an epidemic small-pox 
pervaded Scotland, and many persons passed through a mild form 
of the disease. The term modified small-pox was now introduced, 
and generally adopted. Dr. Monro, in 1818, published a volume 
on the subject [Observations on the different kinds of Small-pox, 
and especially on that which sometimes follows Vaccination), 
which attracted great attention. The more elaborate work of Dr. 
Thomson, of Edinburgh, {Jin Account of the Varioloid Epidemic,) 
which appeared in 1820, occasioned much discussion among medi- 
cal men, but their confidence in vaccination was in no degree shaken. 
In 1824, small-pox prevailed epidemically in Sweden, and attacked 
a considerable number of vaccinated persons. In 1825, an epidemic 
assailed London, where the bills of mortality announced 1300 deaths 
by small-pox, among whom were several persons who believed that 
they had been vaccinated. Similar epidemics subsequently per- 
vaded France (1826 and 1827) and the northern parts of Italy (1829). 
In the same year, the government of Germany, who had always 
encouraged and even enforced vaccination, took alarm ; and then 
began the practice of revaccination, which has formed so striking 
a feature in the medical history of those countries for the last ten 
years. Within the last two years, the same practice has been 
adopted voluntarily by vast numbers of persons both in France and 
England. 

In 1 833-4, small-pox prevailed epidemically at Ceylon, (Report on 
Small-pox, as it appeared in Ceylon in 1833-4,) when a considera- 
ble number of the vaccinated died ; and on several occasions, both 
prior and subsequent to this date, it made great devastations in 
Hindostan, and the vaccinated have not been exempt from the 
calamity. 

In 1S38, small-pox again raged epidemically in London ; the 



PHENOMENA. 521 

admissions into the Small-pox Hospital in that year more than 
doubled the average number received annually prior to the discov- 
ery of vaccination. Two-fifths of the admissions consisted of per- 
sons who had been vaccinated. Many had the disease severely, 
and more than twenty of the number died. In the same year, 
also, small-pox prevailed extensively in the British army. 

These historical details cannot be read without the conviction 
that all idea of banishing small-pox from the earth is vain and illu- 
sory. 

II. PHENOMENA. 

The regular course of cow-pox is as follows. On the third day 
from the insertion of the virus, the wound appears red and elevated. 
By aid of the microscope, the efflorescence surrounding the inflamed 
point will be distinctly perceived, even on the second day. On the 
fifth day, the cuticle is elevated into a pearl-coloured vesicle, con- 
taining a thin and perfectly transparent fluid in minute quantity. 
The shape of the vesicle is circular or oval, according to the mode 
of making the incision. On the eighth day, the vesicle is in its 
greatest perfection, its margin turgid and sensibly elevated above 
the surrounding skin. In colour, the vesicle may be yellowish or 
pearly. The quantity of fluid which it contains varies much. 
When closely examined, the vesicle exhibits a cellular structure. 
The cells are from ten to fourteen in number, by the floor of which 
the specific matter of the disease is secreted. The vesicle possesses 
the umbilicated form belonging to variola. 

On the evening of the eighth day (after the incision), an inflam- 
matory circle, or areola, commences at the base of the vesicle. The 
skin becomes tense, red and painful for a considerable extent around. 
The figure of the areola is perfectly circular. In some cases, the 
subjacent cellular membrane participates in the inflammatory action, 
and occasionally the glands of the neck swell. The areola continues 
to advance during the ninth and tenth days. On the eleventh, it 
begins to fade, leaving, in its decline, two or three concentric circles 
of a bluish tinge. The vesicle has by this time either burst, or been 
opened by the lancet, and a scab forms of a circular shape, and of 
a brown or mahogany colour. By degrees this hardens and black- 
ens; and, at length, between the eighteenth and twenty-first day, 
drops off, leaving behind it a cicatrix of a form and size propor- 
tioned to the prior inflammation. A perfect vaccine scar should 
be of small size, circular, and marked with radiations and indenta- 
tions. 

Until the eighth day, the constitution seldom sympathizes. At 
that time, however, slight febrile excitement generally comes on. 
There is, however, much variety observable here. Sometimes 
scarcely any constitutional disturbance is perceptible. It is not un- 



522 VACCINATION. 

common to find the child's body covered generally or partially with 
a papular eruption of a lichenous character, from the ninth to the 
twelfth day, or even later. It is seldom seen in adult vaccination 5 
but is frequent in children of full habits, in whom numerous vesi- 
cles had been raised, which discharge freely. The irregularities and 
anomalies of cow-pox are various. That most commonly observed, 
is when the vesicle, at a very early period, becomes prematurely 
red and itching; a small acuminated, conoidal pustule is perceived 
on the eighth day, surrounded by a slight areola of irregular shape. 
The contained fluid, instead of being a clear and transparent lymph 
is opaque, and of a light straw colour. The succeeding scab is 
small, and drops off prematurely. 

In another variety, the specific inflammation proves very violent. 
It extends from shoulder to elbow, and sometimes runs into genuine 
erysipelas. The vesicle, instead of drying into a hard scab, is con^ 
verted into an ulcer, discharging profusely, and leaving behind it a 
large scar of the size of a common wafer, in which neither rays 
nor depression can be traced. The question, how far such severe 
local irritation interferes with the constitutional result of cow-pox, 
has never been satisfactorily determined. 

A third variety exhibits, about the sixth or seventh day, the vesi- 
cle partially inflamed and scaly. A species of psoriasis takes place 
of variola. No confidence can be placed in so defective a process 
as this. 

Cow-pox is occasionally retarded in its progress without any ob- 
vious cause. We have never known the period of retardation to 
exceed sixteen days. 

The proper time at which lymph may be taken, so as to obtain 
it in the most efficient state for -propagating the disease, has been 
a subject of much discussion. The facts bearing on this question 
are, we believe, as follows: The younger the lymph is, the greater 
is its intensity. The lymph of a fifth-day vesicle, when it can be 
obtained, never fails. It is, however, extremely powerful up to 
.the eighth day, at which time it is also most abundant. After the 
formation of the aroela, the true specific matter of cow-pox be- 
comes mixed with variable portions of serum, the result of com- 
mon inflammation, and this diluted lymph is always less efficacious 
than the concentrated virus. After the tenth day, the lymph be- 
comes mucilaginous and scarcely fluid, in which state it is not at 
all to be depended on. Out of a dozen incisions made with such 
viscid lymph, not more than one will prove effective. 

Infantile lymph is more to be depended upon, than that obtained 
from adults. The matter of primary is more energetic than that of 
secondary vaccinations. These statements may serve as a guide to 
the surgeon in the important matter of selecting lymph with which 
the operation is to be performed. 

Another matter worthy of consideration is the mode of making 
the incisions, so as to insure the best and most certain results. 



THEORY. 523 

We know that, provided the lymph be good, it matters little in 
what way the virus be applied, but we have reason to believe 
that the following is the most uniformly successful mode. Let 
the lancet be exceedingly sharp. It should penetrate the chorion 
to a considerable depth. In making the incision, the skin should 
be held perfectly tense between the forefinger and thumb of the 
left hand. The lancet should be held in a slanting position, and 
the incision made from above downwards. We would recom- 
mend, that with lymph of ordinary intensity three or four vesicles 
should be raised, and that these should be at such distances from 
each other as not to become confluent it! their advance to matu- 
ration. 

Vaccine lymph should always be used in a fluid state, and direct 
from the arm, whenever practicable ; for it is a very delicate secre- 
tion, and the smallest fermentative process in it is liable to alter its 
qualities, and to occasion that irritable sore, which we have named 
as the most frequent of the anomalous appearances. 

III. THEORY. 

It would lead us into too wide a field to follow out the views 
which have at different times been taken regarding the modus 
operandi of vaccination. Jenner originally proposed and steadily 
adhered to the notion, that cow-pox and small-pox were iden- 
tical in their nature, and that vaccination is only a milder form of 
inoculated small-pox. This opinion has received a very remarkable 
corroboration in the recent experiments of Mr. Ceely of Aylesbury, 
which have proved that the cow may be inoculated with variolous 
matter, and that, in passing through the body of the animal, the 
matter is converted from small-pox into vaccine. But though it 
be admitted that cow-pox and small-pox have a common origin, it 
by.no means follows that they are identical diseases, acknowledg- 
ing the same laws. The immediate effects of the two poisons 
undoubtedly differ. The local inflammation is different, and the 
constitutional influence is different. It would be unfair therefore 
to~ argue regarding their ulterior effects without reference to the 
results of experience. Now it is impossible to call in question the 
fact that vaccinated persons are more liable to attacks of small-pox 
than those who have once undergone that disease. The one is 
now very common. The other was always considered as a rare 
event. 

Among the circumstances that materially influence the protecting 
power of cow-pox is time. In the early periods of vaccination 
(1800 to 1S05), the practice of inoculating after cow-pox, so as to 
test its prophylactic power, was carried to a great extent, and many 
thousands were exposed to the variolous effluvium with impunity. 
Since the year 1S08, these experimental testings have almost entirely 
ceased, and we consequently know very little concerning the effect 



524 VACCINATION. 

of inoculation at long intervals from the date of vaccination. But 
it is a matter of general notoriety, that small-pox, taken casually 
after vaccination, is very rare under the age of eight years. The 
protective power may be considered as nearly complete for that 
period. About the ninth or tenth year of life, small-pox after vac- 
cination begins to be met with. It increases in frequency at the 
period of puberty, and is still more common between the ages of 
18 and 25. With these facts before us, it is impossible to conceal 
the apparent conclusion that time lessens the power of resistance 
to the variolous germ. 

The influence exerted by an atmospheric constitution over the 
power of variolous resistance, opens a wide but hitherto neglected 
field of inquiry. Having now witnessed in London two severe 
epidemic visitations of small-pox, we have no hesitation in stating 
that such influence is undoubted. The fact does not, from its very 
nature, admit of direct proof, but the number of persons attacked 
during epidemic seasons, who had successfully resisted small-pox 
contagion commiuiibus annis, offers an argument in favour of the 
position, which to our minds is irresistible. 

We come now to apply these views of vaccine pathology to the 
examination of the two practical measures suggested of late years 
to remedy the acknowledged defects of vaccine influence. The first 
of these is recurrence to the cow for supplies of primary lymph. 
The second is revaccination at distant intervals from the date of the 
primary process. 

1. Recurrence to the cow for primary lymph. — The im- 
pression that vaccine virus decays in power in proportion to the 
number of times that it makes the circuit of the human body, has 
long prevailed, and is steadily gaining ground. In all parts of the 
Continent, and in England, it has led to the frequent trials of lymph 
recently obtained from the cow. 

Persons vaccinated by Dr. Jenner himself, in the very infancy 
of the practice, before such deterioration could possibly have taken 
place, have undergone small-pox in after life. Such occurrences 
are now more common than formerly, but much may be attributed 
to the extension of the practice of vaccination. The Royal Jenne- 
rian Institution of London employs now the same lymph which 
has been in use since the year 1806, when the Institution was 
founded. According to this authority, lymph recently obtained 
from the cow does not generate a vesicle in any way superior to 
that produced by the old lymph. [Report of the Royal Jenne- 
rian Institution, 1836.) The same result was obtained in Italy, 
in 1829, when the alarm of epidemic small-pox induced the Pied- 
montese physicians to try a variety of new stocks of lymph. We 
are informed by Dr. Griva, (Epidemia Vainoloso del Torino, 
1829,) chief of the Vaccine Establishment at Turin, "that no per- 
ceptible difference was to be traced between the aspect and progress 



THEORY. 525 

of the old and the new, the primitive and the long humanized 
virus." In Germany the plan of recurrence to the cow has been 
largely tried of late years. In Wirtemberg alone, between 1831 
and 1836, forty varieties of primitive lymph were successfully em- 
ployed. The notion of superior efficacy attaching to the new 
lymph was, however, not generally entertained. (Heim, Histo- 
rische Kritische Durstellung der Pockenseuchen.) On the other 
hand, we are bound to acknowledge that the Small-pox Hospital 
of London changed their old stock of lymph for more recent mat- 
ter in 1837, and that a marked improvement was perceived in the 
resulting vesicles. The local inflammation was more severe, the 
constitutional symptoms were more violent ; the virus was more 
energetic ; the most minute incision took effect, and the lymph 
given out on the ninth and tenth day was still in an active state. 
The National Vaccine Establishment has also, on several occa- 
sions, varied their stock of lymph with advantage. In France, a 
new variety of vaccine lymph, obtained from the dairies of Passy, 
near Paris, and called Passy lymph,*was brought into use in 1836, 
and is considered by many as superior to the old stock. In 1838, 
Mr. Estlin of Bristol opened a new source of lymph from a dairy 
in that neighbourhood. It has been found very energetic, and is 
now employed in many parts of England in preference to the lymph 
of the National Vaccine Establishment. [With regard to the more 
certain and permanent protective power of vaccine matter, taken 
directly from the cow, over that which has been transmitted more 
or less frequently through the human system, the committee on 
vaccination, in a recent report (Feb. 1S45) made to the Academy 
of Sciences, observe : " The greater intensity of new vaccine mat- 
ter, as compared with that long in use, is a fact definitely estab- 
lished by experience in England, Germany, Italy, and France. 
But is this greater intensity coupled with a greater preservative 
power ? or, as the report puts the question — Is there any relation 
between the lesser or greater intensity of the local phenomena and 
the protective power of the variolous matter ? The experiments 
made on this point show that the protective power of vaccine mat- 
ter is not proportioned to the intensity of the local symptoms, but 
that vaccination, with matter taken from the cow, is more certain 
than old vaccine matter. Admitting that the protective power of 
vaccine matter diminishes with time, should it be renewed, and if 
so, how ? Has the greater or lesser intensity of the local pheno- 
mena of vaccination any relation of its preservative power ? The 
diminution of power, according to the report, is undoubted. 

As to the means of renewal, the first mode employed was the 
transmission of vaccine matter from man to the cow — an experi- 
ment frequently performed as a matter of curiosity, but only re- 
cently sought to be rendered a means of restoring to the vaccine 
matter its pristine lost energy. The authors of several of the me- 
moirs maintain that the cow, when thus vaccinated, restores the 



526 VACCINATION. 

vaccine matter unaltered, and therefore unregenerated, but the 
commission of the Academy think this conclusion too absolute : in 
fact, it has been established by the experiments of the author of 
one of the memoirs, that vaccine matter taken from man is re- 
generated during its transmission through the cow. The same fact 
results from thousands of experiments made in Bavaria under the 
direction of government. Vaccine matter thus regenerated, failed 
in less that 1 case per 100, while the failures of the old vaccine 
matter were nearly 3 per cent. Would it not be better to transmit 
the vaccine matter through several cows in succession than through 
one only ? The mode, however, which should be preferred to all 
others — the only one on which we can entirely rely — is, as recom- 
mended by JENNER,to obtain vaccine matter from its original source. 
Several circumstances seem to show that the cow-pox is perhaps 
of less frequent occurrence than is commonly thought, and the com- 
missioners suggest that those who happen to meet with it, should 
not content themselves, as has been hitherto done, with trans- 
mitting it to man, but shoukTtransmit it to other cows, and thus 
regenerate the infection. 

The results are 1st. Vaccine matter taken directly from the cow 
causes local symptoms of greater intensity ; its effects are also more 
certain than those of old vaccine matter, but after being transmitted 
for a few weeks through the human subject, the local intensity dis- 
appears. 

2d. The preservative power of vaccine matter does not seem to 
be intimately connected with the intensity of the symptoms of 
vaccination ; nevertheless it is prudent to regenerate vaccine matter 
as frequently as possible, to preserve its protective power. 

3d. The only mode of regenerating vaccine matter deserving of 
confidence is to procure it from the cow." 

In 1838, Professor Dunglison obtained from Mr. Estlin, of 
Bristol, vaccine matter eleven removes from the cow. Dr. Kirk- 
bride, after an extensive trial, observes that his own observations 
induced him to put more confidence in its prophylactic powers than 
in that of the old virus.] 

2. Revaccination. — By many of the physicians of Germany, 
this measure is extolled as scarcely less important in its effects, nor 
less widely applicable, than vaccination itself. The authorities in 
Paris, on the other hand, have reported to the French government 
against the necessity of revaccination, and there is really some diffl 
culty in deciding on the actual merits of the plan. The Germans 
aver that few, if any, of the recently revaccinated have fallen under 
the influence of small-pox, but the time which has elapsed since 
the general adoption of the measure detracts from the value of 
such a statement. The practice may be recommended for its safety, 
even if it be much less serviceable than the Germans contend for. 
We have sufficient facts before us to state with confidence that it 



THEORY. 527 

need never be recommended prior to the tenth year of life, and that 
the age best fitted for it is from the period of puberty to that of 
confirmed manhood. 

[The question of the propriety of revaccination has become one 
of great interest. Without entering here into any discussion of its 
merits, it will be our object to state briefly, the evidence which has 
led to a general belief of its necessity. The most complete inves- 
tigation of this important subject has been undertaken within the 
last six years, by committees appointed by the French Academy of 
Sciences. In 1840, the following question was proposed by that 
body : — " Is the preservative power of vaccination absolute, or 
merely temporary? If it is temporary only, determine by accu 
rate experiments, and authentic facts, what is the period for which 
the vaccine matter exerts its protective influence against small- 
pox." The result of this inquiry is in substance as follows : — An 
attentive examination of what occurred during thirty epidemics 
of small-pox in France shows two important facts — First, that 
somewhat more than one-third of the entire number of persons 
attacked with the small-pox had been vaccinated ; secondly, that 
the mortality among the vaccinated persons was very small. Ac- 
cording to the author of one of the memoirs, more than one-third 
of those attacked in the epidemics which occurred at Montbeillard 
had been vaccinated, but there was no corresponding increase in 
the amount of mortality amongst the vaccinated patients ; and the 
same result was observed in the epidemic of 1828 at Marseilles. 
The same results follow from an examination of the epidemics that 
have occurred in England, Sweden, Denmark, Italy, Malta, Ge- 
neva, &c. 

The fact, then, being established, that vaccinated persons can 
become affected with small-pox, and the proportion so attacked 
during epidemics being nearly determined, a most important pro- 
blem remained to be solved — viz., what was the condition of the 
vaccinated persons affected as regarded the mere fact of their vac- 
cination ? The authors of all the memoirs agree in stating that 
vaccinated persons were not affected indiscriminately, or by chance, 
as it were; on the contrary, the small-pox seems to make a kind of 
selection from amongst them. With some exceptions, the small- 
pox attacks those who have been vaccinated since a long period, 
and spares those who are recently so. An examination of the 
tables published in various parts of Europe, proves positively that 
children are seldom attacked with small-pox before the ninth year 
of vaccination, and also proves the converse fact, that it attacks 
in preference persons who had been vaccinated ten, fifteen, twenty, 
thirty, or even thirty-five years previously. 

A general fact, which might be anticipated from the history of 
eruptive complaints is, that after the age of thirty-five years, the 
aptitude of vaccinated persons to contract small-pox becomes so 
slight that it may be considered as having vanished. An investi- 



528 VACCINATION. 

gation of the facts relative to the occurrence of small-pox in vacci- 
nated persons, lead to the three following conclusions: — 

1st. The protective power of vaccination is absolute and general 
for the first five or six years, and even to the eleventh or twelfth 
year, to judge from the experiments on revaccination. 

2d, After the foregoing period, a part, but a part only, of those 
vaccinated, again become liable, especially under the influence of 
an epidemic, to contract small-pox. 

3d. The greater number of those vaccinated probably remain 
completely protected from small-pox during their entire life. 

Is it necessary to vaccinate the same person several times ? and 
if so, after the lapse of how many years should the revaccination 
be performed ? On this head the report first refers to the fact that 
the revaccinations, performed for a considerable period after the 
discovery of vaccination, did not succeed, except in some rare 
cases, because they were performed too soon after the primary vac- 
cination. But when at a later period experience showed that the 
protective power of vaccination diminished with time, the practice 
of revaccination was resumed, and then succeeded beyond expec- 
tation. In some parts of Germany, especially, revaccination was 
practised universally in the army, and even in civil life. Physicians 
also who had had small-pox in some instances revaccinated them- 
selves, with success, of which Dr. Heim is a remarkable example. 
He attended on his brother for three weeks while he laboured 
under confluent small-pox, and three weeks after having gone 
through this decisive trial, he vaccinated himself, and had pustules 
almost of the ordinary size. Dr. Moeeau, the celebrated accou- 
cheur, who had small-pox in early life, revaccinated himself three 
times with success. 

A document, published by the government of Wurtemberg, 
which showed that of 1677 persons affected between 1S31 and 
1836 with small-pox, 1055 had been vaccinated, contributed greatly 
to extend the practice of revaccination in Germany and in the 
north of Europe. la France, the statistics of epidemic small-pox 
show that the number of vaccinated persons attacked with small- 
pox constitute more than a third of the whole number of patients 
affected. It is impossible, therefore, to doubt the propriety of prac- 
tising revaccination. It is during epidemic small-pox especially, 
that the utility of revaccination becomes obvious. Not only have 
individuals been thus protected, but the spread of the epidemic has 
been arrested. 

In Prussia revaccination has been practised in the army, since 
1833, and the small-pox has been almost entirely extirpated. In 
Wurtemberg but one case of variola occurred in five years among 
14,3S4 revaccinated soldiers, and 3 only among 29,864 revaccinated 
civilians. Epidemic small-pox has not appeared in France since 1830, 
the period when revaccination was commenced. The authors of 
the memoirs agree that during epidemics it is prudent to revaccinate 



THEORY. 529 

about the eighth or ninth year. The answers given by the com- 
petitors for the prize to the questions proposed by the Academy, 
may be thus summed up : — 

1st. The preservative power of vaccination is absolute for the 
majority, and temporary for a small number ; and even in the lat- 
ter it is absolute until adolescence. 

2d. Small-pox rarely attacks those who have been vaccinated 
before the age of ten or twelve, from which age, until thirty or 
thirty-five, they are particularly liable to small-pox. 

3d. In addition to its protective power, vaccination so modifies 
the animal economy that it attenuates the symptoms of small-pox, 
abridges its duration, and considerably diminishes its danger. 

4th. Revaccination is the only known method of distinguishing 
those vaccinated persons that remain protected from those that do 
not. 

5th. The success of revaccination is not a certain proof that the 
person in whom it succeeds was liable to contract small-pox ; it 
merely establishes a tolerably strong presumption that they were 
more or less liable to be so. 

6th. In ordinary periods revaccination should be practised after 
fourteen years, but sooner during an epidemic. 

Professor Chomel, of Paris, a warm advocate of revaccination, 
has expressed the opinion in his lectures, that we should not hesitate 
to recur to it as a measure of the greatest utility, and that it will not 
be long before the authorities are convinced of the necessity of 
making it compulsory, as a general sajiatary measure. Professor 
Chapman holds this language : " Now from these data it is proba- 
ble, perhaps certain, that by this time the system regains, in many 
instances, at least, its sensibility to the vaccine infection, and it may 
be presumed, in the same way, to that of small-pox. The lesson is 
hence inculcated, to test it in all cases by revaccination. No apolo- 
gy, indeed, can be made for the omission. To doit is our bounden 
duty, and any neglect on our parts may be deemed a flagrant mis- 
demeanour, for which we must be held responsible."* 

One of the chief grounds on which the utility of revaccination 
has been combated, is, that the propriety of the measure once re- 
cognized, public confidence in the preservative power of vaccine 
would be diminished or destroyed. The futility of this idea is ably 
shown by Dr. Chomel, in an extract from one of his clinical lectures 
delivered at the Hotel-Dieu, during the session 1842-43. 

"Certainly, if it were proved that a second vaccination was a 
useless and insufficient preservative against an attack of secondary 
small-pox, there would be some reason in abstaining from spread- 
ing among the people ideas which could disturb their confidence; 
but innumerable facts depose against this conclusion. It is false, 
too, that revaccination condemns primitive vaccination; it only 

* [Lectures on the more important Eruptive Fevers, &c, p. 106.] 
34 



530 VACCINATION. 

proves that this has not an absolute and unlimited efficacy, that its 
preservative powers become enfeebled in time, and that they must 
be renewed by a new vaccination. Besides, let us suppose that 
this false opinion reigned among the people, ought physicians to 
suffer themselves to be guided by an erroneous public notion, and 
not by their own conviction ? What inconvenience is there in a 
vaccinated person undergoing the operation a second time ? None ! 
It occasions even no interruption to the daily habits of the person. 
If, after several days, the vaccine pustules are not developed, you 
have the satisfaction of knowing that the individual is for some 
years safe from any attack of variola. If, on the contrary, the vac- 
cine succeeds, we must conclude that an attack of small-pox might 
sooner or later have occurred, and that by this precaution the indi- 
vidual will for the future be preserved from it. Let us suppose 
now that an individual predisposed to secondary small-pox will not 
be revaccinated, and that he is attacked with the disease, how very 
different is the position of this person with one who has submitted 
to revaccination. One by taking an insignificant precaution will 
suffer from no inconvenience, whilst the other, supposing that he 
has only simple discrete variola, will be obliged to remain in bed 
for some days, and if it should be confluent, what danger will be 
not run? In regard, then, to this, there can be no doubt; the in- 
conveniences on one side, and the advantages on the other, are too 
evident. There is, besides, a reason of morality and public interest 
which is strongly in favour of my opinion. A person who is re- 
vaccinated, not only preserves himself against an attack of small- 
pox, but the security will extend to those who might have been 
exposed to the contagion, had that individual, instead of being re- 
vaccinated, had an attack of small-pox. This is an argument, I 
conceive, of great weight in favour of revaccination. Besides, by 
this means we may rationally anticipate sooner or later to destroy 
variola altogether. This consummation will indeed be consoling, 
and worthy in every way of our art."] 



531 



CHAPTER XL 



MEASLES. 



[Syn. — Rubeola, Morbilli, Febris morbillosa; Rougiole, Fievre Morbilleuse, Fr.; Maseru, 
Masernkrankheit, Kleine Pest, Germ.] 

The terms, The Measles, (Cullen,) Rubeola, (Willan, Sal- 
vages,) Morbilli, (Sydenham, Morton,) are employed in the pre- 
sent day as synonymes to designate a disease, the distinguishing 
characters of which are, a continued contagious fever, accompanied 
by a peculiar exanthema or rash, generally combined with inflam- 
mation of the mucous membrane of the respiratory organs. 

The earliest writers on measles have created no little confusion 
by describing the small-pox and measles as the same disease, ad- 
mitting, in their judgment, of some variation in its forms. Rhazes 
himself, in a tract published in the ninth century, (De Variolis et 
Morbilli, A. D. 14S6, transl.,) considers the measles and small-pox 
as the same disease, requiring a similar mode of treatment ; but he 
was more careful than any of his countrymen to point out some of 
their specific differences. However extraordinary it may appear, 
this error was transmitted by medical authors through eight or nine 
centuries. The sagacious Sydenham distinguished and described 
great differences between the two diseases, as may be seen in his 
account of the Variolas regalares, A. D. 1667-8, and of the Mor- 
billi, A. D. 1670. Nevertheless, Sydenham adverts to the analo- 
gies which had caused physicians to confound these diseases, and 
particularly to the decline of the measles on the eighth day, " Quo 
tempore vulgus (a spatio, quo perdurare solent variolas) deceptum, 
eosdem introverti ad firm at ; licet revera morbilli cursum a natura 
destinatum absolverint." {Op. Univ., sect. iv. cap. 5.) 

In the history of scarlatina it has been shown how long that dis- 
ease was mistaken for a severer form of measles, and that Morton 
with many subsequent writers, even so recently as the end of last 
century, contended that they differed only in degree and not in kind. 
It was not until the appearance of Dr. Withering's Essay on 
Scarlet Fever, in 1793, and Dr. Willan's Treatise on Cutaneous 
Diseases, that the profession at large was convinced of the distinct 
nature of the two diseases. The observations of these, as well as 
subsequent writers, have satisfactorily shown that, in the precursory 
symptoms, in the characters of the rash, in the accompanying lesions 
of internal organs, and in the sequelae, there are solid reasons for 
believing these two diseases to be induced by separate specific poi- 



532 MEASLES. 

sons. Frank, in his Observations upon the Exanthemata, (vol. 
ii. p. 216, French edit.,) has remarked that, as "there is no exan- 
thema which does not occasionally exist without its peculiar fever, 
so, on the other hand, there is not one of the exanthematous fevers 
which does not, in certain cases, pursue its course without any 
cutaneous eruption, and with the same consequences as in other 
cases." The accuracy of this remark is more apparent in the his- 
tory of scarlatina than of rubeola ; nevertheless, the irregularities 
in the symptoms of the latter disease manifested in different indi- 
viduals, and in distinct epidemics, are sufficiently striking to warrant 
us in describing three forms or varieties of rubeola. 

We shall first describe the more ordinary form of measles (Ru- 
beola vulgaris); secondly, that in which the action of the poison, 
as in one of the varieties of scarlatina, is limited to the skin (Ru- 
beola sine catarrho) ; and, thirdly, that form in which the intensity 
of the poison is manifested by the most malignant symptoms 
(Rubeola maligna). 

A. RUBEOLA VULGARIS. 

In this form there are symptoms of febrile disturbance, generally 
for several days before the appearance of the characteristic rash 
In the slighter cases the premonitory symptoms are those of catarrh, 
accompanied with profuse watery discharges from the eyes and 
nose: in the more severe cases, on the first and second days, there 
are irregular shiverings alternating with heat of skin, general lassi- 
tude or listlessness, occasional flushing, giddiness, sensation of pain or 
weight across the forehead, with drowsiness, soreness of the throat 
and hoarseness, thirst, furred tongue, frequent pulse, and in some 
cases epigastric tenderness with sickness or vomiting. On the third 
and fourth days these symptoms become aggravated, the eyes smart, 
the conjunctiva becomes suffused, the eyelids swollen, and the tarsi 
red, with copious secretion of watery fluid from the eyes and nostrils, 
frequent sneezing, harsh dry cough, and oppression of breathing. 
It is during this accession of symptoms that the efflorescence makes 
its appearance. In those who have a delicate florid skin, or who 
are living in a high temperature, the rash sometimes appears par- 
tially on the third day ; but when the skin is dark or thick, or when 
the patient is exposed to cold, it may not come out till the fifth or 
sixth day; in general, however, it appears on the fourth day. It 
is first visible on the head, around the margin of the hairy scalp, 
behind the ears and about the temples, then, on the forehead, nose, 
cheeks, and throat, exhibiting elsewhere, in the course of the first 
day, only a few scattered red specks like flea-bites. The rash con- 
sists of small irregular red dots, slightly prominent and sensible to the 
touch, especially on the face, of a less bright tint than that of scarla- 
tina ; sometimes, however, as in the malignant measles, the colour 
is dark and livid; to those cases Willan applied the term Rubeola 



VARIETIES. 533 

nigra. The colour of the skin vanishes on pressure, but rapidly 
returns when that is removed. The rash in some cases is so abun- 
dant, that but little of the skin is left in its natural state; the 
red spots become confluent, and form patches, which frequently 
assume a semilunar or crescentic shape. These patches are slightly 
raised, and give to the finger the sensation of an uneven surface. 
In the severer cases, and especially in infants, the rash is often in- 
terspersed with papulae, and during the height of the efflorescence, 
vesicles sometimes appear on the neck, breast, and arms. In many 
cases, at the height of the eruption, there is swelling of the face, 
and especially of the eyelids, which are sometimes so swollen as 
to close the eyes for a day or two. The eruption does not at once 
cover the whole body, but having appeared, on the third or fourth 
day of the febrile attack, on the head, face, neck, and slightly on the 
upper extremities, on the fifth day spreads over the trunk and upper 
extremities, and on the following day becomes visible on the lower 
extremities. At this period the efflorescence is said to be at its height. 
On the succeeding three days the rash gradually fades and disap- 
pears, first on the face, then on the trunk and upper extremities, 
and lastly from the lower extremities. When the rash begins to 
decline on any part, the cuticle becomes dry and rough, and soon 
after separates in the form of scurf. Hence arises a troublesome 
itching of the skin, which continues from the seventh to the tenth 
day. It is to be observed that, with the appearance of the rash on 
the surface of the body, small dark red patches, more or less con- 
fluent and of nearly similar form, may be detected on the palate, 
uvula, and tonsils. This state of the fauces occasions a sensation 
of soreness in the throat, but is not followed by any lesion of the 
part, and disappears as the rash declines from the surface of the 
body. 

The inflammation of the eyes, the discharge of tears, the sneezing 
and hoarseness, generally cease on the decline of the efflorescence 
about the seventh day ; at least the swelling of the eyelids and 
watery secretion are much abated at that time. The febrile symp- 
toms do not sensibly diminish on the appearance of the rash, but 
are often somewhat aggravated ; the more distressing symptoms, 
however, generally abate on the sixth day. About the ninth or 
tenth day, or even at an earlier period, especially in children, diar- 
rhoea often supervenes, and is troublesome for days afterwards. 
Between the fourth and sixth days, epistaxis, or, in adult females, 
uterine hemorrhage, sometimes appears. In many instances upon 
the decline of the eruption, the pectoral affection becomes predomi- 
nant, and often places the patient in danger. This is indicated by 
the increased frequency of cough, hurried breathing, and aggravation 
of the febrile symptoms. Upon careful auscultation, the existence 
of diffused bronchitis, and occasionally the physical signs of circum- 
scribed pneumonia, or pleuritis, may be detected; these affections 
are often prolonged for several weeks beyond the ordinary duration 



534 MEASLES. 

of the disease. More rarely, the decline of the rash in children is 
succeeded by acute inflammation of the larynx or treachea. 

Such is the usual course of the measles in their more common 
and regular form, but some peculiarities are occasionally observed, 
which require to be noticed. Thus the eruption, sometimes anti- 
cipating the ordinary time of its appearance, comes out on the 
second day ; in other instances the catarrhal symptoms exist for a 
fortnight or longer before the appearance of the rash. In some 
instances the rash appears first on the body instead of the face, and 
in some rare cases it has been confined to those parts without 
spreading to the extremities. Again, it has occasionally been ob- 
served, that the rash, after having declined, has reappeared with 
symptoms of fever. Dr. Willan, in his Reports, p. 106, has re- 
lated two remarkable cases of this anomaly; and Dr. Conolly has 
recorded a nearly similar case, where the eruption came out and 
seemed to be disappearing at the usual period, when it suddenly 
broke out again, and to such an excessive degree, as to make it 
impossible to recognize the features. {Cyc. Pract. Med., art. Hys- 
teria.) Frank has also detailed a case of the same irregularity 
(torn. ii. p. 377). Some other irregularities in the course of measles 
have been occasionally noticed. Thus Dr. Heberden met with a 
case where salivation appeared to be vicarious of the catarrhal 
symptoms. Sometimes, also, muscular twitchings, or even convul- 
sions, precede the eruption. 

B. RUBEOLA SINE CATARRHO. 

When the measles are epidemic, a few cases occur in which the 
eruption goes through its different stages without the usual catarrhal, 
and with very slight febrile symptoms. This variety, first observed 
by Willan, does not protect the constitution from the regular form 
of measles ; and on this account it is rejected by Frank as spurious : 
and Dr. Williams {Elements of Med.) says, that "this reason 
would certainly be sufficient to induce him to acquiesce in this de- 
cision." But this objection cannot be admitted, for, besides the 
opinion of Willan, Bateman, and other writers, that it is a dis- 
tinct variety, the recurrence of measles in the same person has been 
witnessed by Willan, Baillie, and others. 

C. RUBEOLA MALIGNA. 

A more severe form of measles has been noticed to prevail occa- 
sionally, to which the term malignant, or putrid, has been applied. 
During ordinary epidemics, a few cases of this malignant type may 
occur ; but it has been observed sometimes to constitute the pre- 
vailing character of the disease. The eruptive fever and catarrhal 
symptoms are from the beginning severe, the former soon assuming 
the typhoid aspect, while, through the whole course of the disease, 



VARIETIES. 535 

insidious local inflammations, especially of the lungs, arise, and 
which either speedily destroy the patient, or protract the course of 
the disease indefinitely. 

At the commencement there is nothing remarkable, except that 
the fever is violent ; there are extreme restlessness, thirst, and heat 
of skin ; the pulse is frequent, but soft and compressible ; the respi- 
ration hurried : the cough, dyspnoea, sense of tightness, or precor- 
dial oppression, distressing; the eruption comes out irregularly, 
appearing sometimes earlier than usual, receding and reappearing. 
It is seen in irregular patches on different parts of the body, at one 
time red, at another pale, livid, or interspersed with peteehiae or 
ecchymosis. The mucous membrane of the tongue and fauces 
assumes a dusky red or livid colour; there is often sickness or 
vomiting, with abdominal tenderness and frequent dark offensive 
stools. The brain partakes early of the constitutional distress; the 
look is oppressed, and transient delirium passes into coma, or con- 
vulsion supervenes. In the majority of cases, inflammation either 
in the lungs or brain arises, and does not abate with the decline of 
the eruption, while the fever assumes more and more the typhoid 
type, the pulse becoming very frequent. Many patients sink 
rapidly, asphyxiated by the intense congestion of the pulmonary 
mucous membrane; in others, subsultus and convulsions super- 
vene, and speedily destroy the patient: not unfrequently, however, 
life is protracted a considerable time, the powers being gradually 
exhausted by diarrhoea and discharges of the mucous membranes. 

This form of disease is fortunately of rare occurrence, though 
now and then, as has been stated, isolated cases may occur in an 
epidemic otherwise mild. Huxham has described an epidemic of 
malignant measles occurring at Plymouth, A. D. 1745. {De Morb. 
Epidem., vol. ii.) Sir William Watson, who was physician to 
the Foundling Hospital, describes epidemics of malignant measles 
which attacked the children of that institution in the years 1763 
and 176S. In the former 183 were attacked, and 19 died; in the 
latter 139 had the disease, and 6 only died. {Med. Obs., vol. iv.) 
In 1816 a malignant form of measles appeared in Edinburgh, and 
many children died from pulmonary inflammation, the pulse having 
been very rapid, and the eruption irregular, and of a livid colour. 
Similar epidemics have been also occasionally observed in other 
countries. In the autumn of last year (1839) we were called upon 
to assist the medical officers in Christ's Hospital in controlling epi- 
demic malignant measles, which appeared among the boys at Hert- 
ford. The symptoms closely resembled those described by Huxham 
and Watson: of 127 boys attacked seven died of pulmonary in- 
flammation, which resisted the ordinary treatment. 



536 MEASLES. 



[II. COMPLICATIONS. 

Of all the complications of measles broncho-pneumonia is the 
most common. In 167 cases MM. Rilliet and Barthez observed 
24 cases of bronchitis, 7 of pneumonia without bronchitis, and 58 
of lobular broncho-pneumonia. No special character is presented 
in the bronchitis of measles, and dilatation of the bronchi was 
never met with by MM. Rilliet and Barthez, unless the child 
had lived at least ten days after the occurrence of the pneumonia. 
The pneumonia is almost always lobular, involving both lungs to 
a greater or less extent — so that kernels of inflamed lung are found, 
either isolated or united, in every lobe— the posterior and inferior 
portions being those chiefly affected. The same authorities state 
that, compared with pneumonia occurring under other circum- 
stances, the formation of abscesses is very common in that of 
measles, nearly one-half the autopsies exhibiting these, and some- 
times in large numbers. Broncho-pneumonia may arise at three 
periods of the disease. — 1. During the stage of incubation, and the 
first period of the eruption ; 2. During the decline of the eruption ; 
and 3. During convalescence. It is met with more frequently 
during the first of these periods than during the other two put 
together. When pneumonia supervenes during convalescence, it 
may be independent of the disease, and in such cases is lobar ; but 
generally there is a direct connection, and it is then lobular. Some- 
times the pneumonia becomes very chronic, giving rise to the sus- 
picion of pulmonary tubercles, but on examination, after death 
abscess of the lungs is found. Pneumonia is most common in 
young children, whilst bronchitis is met with in those who are 
older. Rilliet and Barthez state that gangrene of the lungs is 
not an infrequent complication. Another common complication is 
inflammation of the larynx and pharynx, occurring usually about 
the fourth or fifth day of the eruption. Of the 167 cases before 
alluded to, in 24 there was pharyngitis, in 19 laryngitis, and in 16 
laryngo-pharyngitis. Rilliet and Barthez regard laryngitis as a 
more special complication of measles than pharyngitis, and believe 
the frequency of the latter due to the simultaneous presence of 
scarlet fever epidemics. In a severe epidemic of measles which 
occurred in South Dublin Union Workhouse in 1S44, Dr. Bat- 
tersby states that a diphtheritic inflammation of the mouth, fauces, 
and 'larynx was the principal complication.* 

Gastro-intestinal lesions are next in frequency to pulmonary. 

Measles may become complicated with other exanthemata. MM. 
Rilliet and Barthez have seen small-pox twelve times, scarla- 
tina seven times, and erysipelas three times in conjunction with 
them. Under these circumstances the diagnosis is often embarrass- 

* [Dublin Journal, Sept., 1845.] 



SEQUELS, 537 

ing. What is more remarkable in such cases is, that the intensity 
of the complication is the inverse of that of the special eruption. 
Thus, when the scarlatina predominates, the bronchitis is most 
severe ; but when the rubeola prevails, the angina is most intense. 
This may be explained by the mutual compensatory functions of 
the skin and mucous membranes, and when the former is com- 
pletely invaded by the scarlatinal eruption, causing the retrocession 
of the measles, the pulmonary affection is augmented.] 



III. SEQUELS. 

Measles are frequently followed by troublesome affections of 
the mucous membrane of the lungs or intestines. The occasional 
supervention of inflammation of some of the tissues of the lungs 
in the course of rubeola vulgaris has already been noticed. Upon 
the decline of the disease, chronic bronchitis, pertussis, or tuber- 
cular disease of the lungs, occasionally supervenes. [MM. Ril- 
liet and Barthez have shown that measles is the origin of 
tuberculization in a considerable number of cases. They express 
their belief that rubeola hastens the development of tubercles, and 
accelerates the progress of those already deposited. Dr. Bouchet 
expresses very strongly the opinion that measles have great power 
in the development of pulmonary tubercles, and accelerates the 
progress of phthisis in children who already are its subjects.] The 
cervical and mesenteric absorbent glands frequently enlarge, and 
occasion great constitutional irritation. Another sequela of measles 
is a troublesome diarrhoea, which greatly exhausts the patient. Oph- 
thalmia and abscesses in the ear, and in the cellular tissue surround- 
ing the parotids, also occasionally supervene. Sometimes aphthae 
appear on the tongue and lining of the mouth, which quickly de- 
generate into formidable gangrenous ulceration ; and in some rare 
cases similar ulceration appears about the pudenda. [Cancrum 
oris is a very frequent sequela of measles; Dr. Gregory says it is 
"much more common after measles than after any other exanthe- 
matic malady."* In two extensive epidemics of measles which 
we have observed within the last ten years in the Children's Asy- 
lum attached to the Philadelphia Hospital, cancrum oris occurred 
to a great extent after both. But it must be borne in mind that 
these children are generally miserably cachectic, and in many in- 
stances suffering from organic diseases. In an epidemic which the 
writer witnessed at St. Joseph's Orphan Asylum, in this city, in 
1845, where there are about one hundred children, nearly all of 
whom are of good constitution, no sequelae of consequence followed 
in a single case.] Various forms of cutaneous affections, more 
especially pustular porrigo and impetigo, are also apt to appear 
after measles. 

* [Lectures on the Eruptive Fevers. London, 1843, p. 110.] 



538 



MEASLES. 



[IV. STATE OF THE BLOOD. 



Andral and Gavarret found that in measles the fibrin never 
exceeded, nor did it ever fall much below Lecanu's average. In 
most cases the corpuscles were above the normal standard. The 
following analyses are quoted from their researches: 

















Residue 


Venesection. 


Day o 


f eruption. 


Water. 


Fibrin. 


Blood corpuscles. 


of serum. 


1st Case 


1 




3 


7602 


2-6 


146-6 


90-6 


2d " 


1 




2 


766-9 


3-0 


140-9 


89-2 


3d u 


1 




3 


781-6 


2-6 


137-1 


78-7 


4th " 


f 1 




2 


786-7 


2-5 


137-5 


73-4 


» 2 




- 


795-8 


2-7 


131-6 


70-1 


5th " t 


[ 1 




2 


792-1 


2-4 


118-6 


86-9 


1 2 




- 


823-2 


3-4 


93-3 


80-1 



The residue of the serum contained on an average 8-4$ of inor- 
ganic constituents, which was one of the highest amounts that 
occurred in the course of their researches. 

The patient in case 3 had also been bled on the first day of the 
eruption : the second bleeding in case 4 was performed on the 
second day after the disappearance of the eruption. 

The young woman from whom the blood in case 5 was taken, 
presented so strongly the general appearances of anemia in conse- 
quence of excessive menstruation, that the amount of corpuscles, 
118-6, may be regarded as very high: the second venesection was 
performed after the disappearance of the eruption, and when symp- 
toms of tubercular phthisis were very apparent.*] 



V. ANATOMICAL CHARACTERS. 

It is very rarely that death occurs during the eruptive stage of 
measles, so that the condition of the mucous membrane of the 
trachea and bronchi at this early period is unknown, though it is 
probably more or less involved in the eruption. In unfavourable 
cases the fatal termination generally happens after the decline of 
the eruption, in consequence of some serious pulmonary lesion or 
protracted diarrhoea. Dr. Willan found, in some of his fatal 
cases, « an effusion of lymph mixed with blood, or matter, into the 
cavity of the thorax." Laennec was of opinion that the suffo- 
cating orthopnoea, which sometimes carries off children at the ter- 
mination of measles, was produced by idiopathic oedema of the 
iungs. Dr. Williams says, that if the substance of the lungs 
becomes inflamed, the quantity of fluid effused into them is fre- 
quently so considerable, that it streams as from a sponge as soon 
as the lung is divided. Dr. Montgomery, on the other hand, 
asserts, that in the greater number of cases examined after death 

* [Simon's Animal Chemistry, p. 245.] 



DIAGNOSIS. PROGNOSIS. 539 

by him, the morbid alteration existing was the condensation of the 
pulmonary structure ordinarily found as the effect of pneumonia. 
In the fatal cases recorded by M. Rayer, the most frequent morbid 
lesions discovered were extensive bronchitis, gastro-enteritis, pneu- 
monia, pleuritis, croup, and enlargement of the mesenteric glands. 
( Traite des Maladies de la Peaa.) 



VI. DIAGNOSIS. 

The only disease with which the measles are likely to be con- 
founded is scarlatina. For the distinguishing characters between 
the two see Scarlatina. 



VII. PROGNOSIS. 

The prognosis in measles during the early stage of the disease 
is always favourable ; but a mild attack of the proper symptoms is 
often suddenly converted into a most dangerous disease. It should 
be recollected that the eruption, or the mere disease, rarely puts the 
patient's life in hazard, as we so frequently observe in scarlatina, 
in which the vital powers are so alarmingly depressed by the 
action of the poison ; but in measles the internal inflammation, 
particularly of the lungs, which frequently supervenes, is the chief 
source of danger. [Broncho-pneumonia is the most frequent cause 
of a fatal termination, hardly one out of four or five surviving this 
complication, according to Rilliet and Barthez. This, however, 
applies more strictly to hospital patients.] It is very generally 
admitted that measles are more severe, and attended with more 
danger in adults than in children. Dr. Montgomery dissents from 
this doctrine, and states that, as far as his experience enables him 
to judge, he should pronounce exactly a contrary opinion. (Cyc. of 
Pract. Med.) The most severe cases of measles which have come 
under our notice, have certainly been in adults. The character of 
the prevailing epidemic, and the peculiar type of continued fever 
of the same period, should be carefully weighed in forming the 
prognosis, as well as in determining the treatment of measles. The 
season of the year has a more important influence on the issue than 
on scarlatina or variola : the complaint is more likely to proceed 
favourably and safely in mild than in cold damp weather. When 
measles quickly succeed to other infantile disorders, as pertussis or 
remittent fever, the danger to be apprehended is greatly increased : 
the same may be said when it attacks children disposed to affec- 
tions of the brain or to scrofula. The following are the general 
circumstances which denote danger: — unusual violence of the 
eruptive fever, especially if attended with spasmodic twitches or 
convulsions; the eruption appearing late, and of dark livid colour; 



540 MEASLES. 

the supervention of thoracic or abdominal inflammation ; severe 
headache, with nocturnal delirium ; retrocession of the rash ; ex- 
treme dyspnoea, coming on late in the disease with dusky flush on 
the cheeks and livid lips; the accession of typhoid symptoms; the 
appearance of petechias, or profuse hemorrhages from mucous 
surfaces. 

A favourable prognosis may be pronounced when the eruption 
appears at the usual time, and proceeds regularly over the whole 
body and limbs ; by the mildness of the bronchial affection ; by the 
appearance of moderate diarrhoea; by the softness of the pulse ; by 
the uniformly warm and moist state of the skin, and by the return 
of sound refreshing sleep. 



VIII. CAUSES. 

On this subject Dr. Williams states, " there is not any trace in 
medical history of the origin, or primary causes, of the measles. 
Aaron, a physician of Alexandria, cotemporary with Mahomet, 
and the first-mentioned writer on this subject, does not speak of the 
small-pox and measles as new or unusual diseases. Rhazes took 
it for granted that small-pox and measles wer,e known to Galen 
more than 600 years before his time, being misled by some incorrect 
translation of Galen's works into the Arabian language. The 
passages which he quotes have certainly not the least relation to 
those diseases. Indeed, no description of them, nor the slightest 
collateral hint, appears in the writings of the Greek physicians, 
which could lead us to suppose they had any knowledge on the 
subject.' 7 Some modern writers have held a contrary opinion, and 
a controversy founded on very slight and unsatisfactory evidence, 
was carried on with ardour during a part of the last century, to 
which it is unnecessary more particularly to allude. 

The measles, like scarlatina, now prevail in every climate, and 
at every season of the year, frequently without our being able to 
trace them to any particular source ; so that we must infer that a 
morbillous poison is always in existence, and ready to infect the 
predisposed. It seems to be a law of this and similar poisons, that 
they vary greatly in intensity at different periods ; and thus the 
measles are frequently observed to prevail epidemically rather than 
sporadically, breaking out with great violence for a certain time and 
then declining. The disease, however, is more common in open 
mild winters, and during the spring, than in the summer and autumn. 

Though incident to every period of life, measles are more com- 
monly observed in childhood, at which period the human constitu- 
tion is very susceptible of this and similar diseases. It is admitted 
by all observers, that the body of a person labouring under rubeola 
generates a poison, which, either by contact or diffusion through the 
atmosphere, is capable of producing a similar disease. Measles are, 



CAUSES. 541 

therefore, both contagious and infectious. The contagious nature 
of this disease has often been proved by direct inoculation, either 
with blood drawn from the arm of a morbillous patient, or with 
serum taken from the vesicles, which are occasionally intermixed 
with the eruption. Dr. Home appears to have been the first who 
ventured, about the year 1750, to inoculate for measles with the 
blood of an infected person. His experiments have been repeated 
by Vogel, Brown, Monro, and Tissot, and the result led them 
to suppose that a mitigated and mild form of rubeola followed. 
Similar experiments, however, made by Cullen, Girtannec, 
Rosentein, and Vaidy, were not attended by such mitigation of 
the symptoms, as in their opinions warranted the continuance of the 
practice. In the year 1822, however, Professor Speranza, in an 
epidemic which prevailed at Mantua, inoculated himself and six 
boys in the manner recommended by Home ; they all took the dis- 
ease, which run a mild and regular course. (Williams, op. cit.) 
Dr. Willan inoculated three children with the fluid contained in 
the vesicles, which sometimes appear in the course of rubeola, but 
no effect was produced by the inoculation. He relates the case of 
a lad eighteen years of age, who was inoculated with this lymph 
and with vaccine virus on the same day. The vaccine vesicle ran 
its regular course, and after its decline on the sixteenth day from the 
inoculation, the primary fever of measles set in, which was followed 
by an attack of the rubeola vulgaris. Three children of another 
family were infected from him. [Dr. M. Von Katona,* of Hun- 
gary, in a very malignant and wide-spread epidemic of measles in 
the winter of 1841, inoculated 1122 persons, with a drop of fluid 
from a vesicle, or with a drop of the tears of a patient with measles. 
It failed in seven per cent, of those on whom it was tried ; but in all 
the rest the disease was produced in a very mild form, and not one 
of them died. At first a red areola formed round the puncture, but 
this soon disappeared; on the 7th day fever set in, with the usual 
prodromi of measles ; on the 9th or 10th, the eruption appeared; on 
the 14th, desquamation commenced, with decrease of the fever and 
the eruption; and by the 17th, the patients were almost always 
perfectly well.] The general evidence in favour of the doctrine of 
the infectious nature of measles is strong, and is admitted by all 
writers. The rapid spread of the disease in families, schools, and 
other establishments for children, and the difficulty of protecting 
susceptible persons who happen to associate with the affected, are 
facts which establish the accuracy of this proposition. 

It is rarely that individuals are affected by this poison twice in 
the course of their lives. Dr. Willan affirmed {Medical Facts and 
Experiments) that, after an attention of twenty years to eruptive 
complaints, he had not met with an individual who had twice suf- 

* [Oester. Med. Wochensch., July 16, 1842, and British and Foreign Med. Rev., 
July, 1845, p. 211.] 



542 MEASLES. 

fered from the rubeola vulgaris ; but admits that those who have 
been attacked by the rubeola sine catarrho are not rendered insus- 
ceptible to a second attack. Dr. Home ( Trans, of a Soc. for the 
Imp. of Med. and Chir. K?ioivledge), says that it was not uncom- 
mon for measles to attack the same person twice ; and Dr. Baillie, 
whose authority may be esteemed equal to that of Willan, pub- 
lished two papers, which prove decisively that measles may occur 
a second time in the same individual, accompanied by their peculiar 
febrile and catarrhal symptoms. Similar cases are recorded by Dr. 
Webster. (Med. Chir. Trans., vol. xxii.) It would thus appear 
that the poison of rubeola as well as that of vaccinia, variola, and 
scarlatina, may infect the human system a second time. The ex- 
periments,by inoculation, appear to prove thatthe poison is absorbed 
and carried into the circulation. 

It is an interesting question, how long the poison remains latent 
before the special phenomena of the disease are manifested ? He- 
berden saw four men that were affected with the disease on the 
tenth day after exposure to the infection, one on the thirteenth, and 
two on the fourteenth. Dr. Home, in his experiments, observed 
that the eruption appeared on the sixth day after inoculation. In 
the case of successful inoculation recorded by Willan, the disease 
commenced on the sixteenth day after inoculation, but the vac- 
cinia ran its course in the interval. The period of latency, there- 
fore, may vary from six to sixteen days. [MM. Rilliet and 
Barthez found, in one epidemic at the En fans Ma/ades, the 
period of incubation to vary from 12 to 29 days. Of 38 patients, 
whose duration of residence in the hospital prior to the appearance 
of measles had been noted, there were four in which the eruption 
appeared on the 4th or 5th day ; eight from 9 to 13 days ; twenty 
from 15 to 25 days; and six from 2S to 5S days. Dr. Bouchet, 
in an account of a slight epidemic at the Neckar hospital in 1843,* 
states that a child in the seventh day of the measles was brought 
into a ward in which there were nine little children, only one of 
whom had had the disease. Of the remaining eight, seven subse- 
quently became affected ; five of these, twelve days after the ad- 
mission of the infected child, and the two others on 25th and 26th 
days. During the two months that the epidemic prevailed, 17 
other infants entered the ward, of whom ten only contracted the 
disease, after remaining one 21, and the other 29 days, amid the 
infection. Succeeding new patients did not take the disease, nor 
did it pass into other wards, though they were only separated from 
the infected one, by a boarded partition. Dr. Guersant remarks 
that the accidental, as well as the natural predisposition should be 
regarded. In the examples above cited, the subjects of observation 
were already suffering from other diseases, which might have re- 

* [Manuel Pratique des Maladies des nouveaux-nes et des Enfans a la Mam- 
melle. Par E. Bouchet, Paris, 1845.] 



TREATMENT. 543 

tarded the appearance of the measles.] Various conjectures have 
been entertained respecting the state of the disease at which the 
virus of rubeola is generated. Many think that the poison is not 
disseminated till after the appearance of the eruption, while others 
believe this may take place during the primary fever. We incline 
to this latter opinion. 



IX. TREATMENT. 

The eruptive stage of measles, being seldom attended with dan- 
ger, requires but little interference. It is chiefly necessary to pay 
attention to the regular action of the bowels, to confine the patient 
to bed in a moderate temperature, and to a light farinaceous diet, 
with cooling and demulcent drinks. The heat of skin about the 
period of the appearance of the rash is often considerable ; but it is 
certain that the measles neither require nor bear the free application 
of cold to the surface of the body, which is so grateful and salutary 
in scarlatina, where the heat of skin is distressing ; a cool apartment 
and light bed-clothes, with moderate allowance of cooling drinks, are 
all that is required. The remedies which are often administered at 
this stage of the disease, with the intention of exciting diaphoresis, 
are seldom attended with benefit ; and the emulsions, which are so 
commonly prescribed, have but little control over the accompanying 
bronchial affection. 

[The inhalation of the steam of mucilaginous decoctions, or even 
of boiling water, with or without the addition of a narcotic, the 
writer has found to relieve the distressing cough at the commence- 
ment better than any other means.] 

The treatment now mentioned is in many cases all that is neces- 
sary throughout the course of the disease. Willan, however, adds 
that " an emetic given on the second or third evening somewhat alle- 
viates the violence of the catarrhal symptoms, and contributes to 
prevent the diarrhoea which usually succeeds the measles." The 
mildness of the catarrhal symptoms should not lull the practitioner 
into security, but it should be remembered that active pulmonary 
inflammation may come on at any period of the complaint. It is 
generally upon the decline of the eruption that this danger is to be 
apprehended ; but it is necessary to be alive to the possibility of 
pulmonary inflammation arising at any stage of measles, and by 
frequent examination of its physical as well as general signs, to de- 
tect its first approach. 

The tendency to pulmonary inflammation has raised the question, 
whether bleeding ought not to be adopted as a precautionary part 
of the treatment of measles, or whether it should be postponed until 
pulmonary symptoms have come on ? Sydenham was an advocate 
for bleeding in every stage of measles, when the eruption was at its 
height, when the difficulty of breathing and catarrhal symptoms 



544 MEASLES. 

were urgent, and when the diarrhoea was obstinate. Dr. Heber- 
den contends, that " bleeding with such medicines as the occasional 
symptoms would require in any other fever, is the whole of the 
medical cure requisite hi the measles. (Commentaries, p. 321.) 
Cullen does not appear to have resorted to bleeding in measles, 
unless particular local symptoms rendered it necessary. Dr. Wil- 
liams cautions the practitioner " to remember, even when these 
local lesions are most severe in measles, that they depend on the 
action of a morbid poison, have a certain course to run, and are conse- 
quently less amenable to antiphlogistic treatment than similar lesions 
depending on simple inflammation. 5 ' (Op. cit.) Bleeding, therefore, 
is not to be regarded as a remedy always necessary in measles, 
although blood may be taken from the system with much less risk in 
this than in any of the eruptive fevers. In all cases where pulmonary 
inflammation exists, blood should be taken freely from the arm ; 
but it should be remembered, that although some children bear the 
loss of blood well, there are many who are long in recovering from 
its effects, even when the quantity taken has been small ; hence, in 
children of tender age, it is more prudent to take blood in small 
quantities by cupping, or by leeches applied to the chest, selecting 
some spot where there is a solid resistance to pressure, should it 
become necessary to restrain the bleeding. The quantity of blood 
taken should be more moderate during the eruption, than if the 
symptoms indicate loss of blood after its subsidence, because many 
urgent symptoms become mitigated when the rash disappears. 

[The writer is disposed to look upon general blood-letting much 
less favourably and as less necessary than the author. He believes 
that in very few epidemics or individuals it is required. Local 
bleeding by cups or leeches, on the contrary, will often materially 
alleviate the more annoying symptoms ; but even this should not 
be pushed too far.] 

Antimony, ipecacuanha, and blisters, may be employed to assist 
the abstraction of blood. Sydenham prescribed an opiate every 
night throughout the whole course of measles ; but in the early 
stages of the complaint, and particularly in children, it is seldom 
attended with beneficial results. As an occasional remedy in the 
latter stages, and where free depletion has been resorted to, as re- 
commended by Sydenham, opiates may be useful. If the powers 
of the child do not forbid it, and there be no tendency to diarrhoea, 
one or two doses of calomel and rhubarb should be given at the 
termination of the disease. 

The diarrhoea, which so frequently occurs at the close of measles, 
appears to alleviate the pulmonary symptoms, and, according to 
Bateman, " to prevent some other of the troublesome sequelae of the 
disease." Hence this natural evacuation should not be arrested at 
once, but the secretions regulated by mercurial alteratives. If the 
diarrhoea be protracted, we may find it necessary to prescribe a 
few leeches or a blister to the abdomen, with slight astringents, an 



TREATMENT. 545 

occasional warm bath, and a farinaceous diet. Dissections (Rater, 
op. cit., Rougeole), after death have shown that, in such cases, in- 
flammation of the mucous membrane of the intestines and enlarge- 
ment of the mesenteric glands have existed. 

It sometimes happens that the rash comes out imperfectly, or 
having appeared, suddenly recedes and disappears ; if the retro- 
cession have followed exposure to cold, the use of the warm bath, 
diaphoretics, warm and slightly stimulating drinks, and perhaps a 
mustard poultice to the chest or abdomen, are the remedies most 
likely to be beneficial ; should it disappear from debility, a more 
stimulating plan must be adopted, not because the rash has sud- 
denly disappeared, but on account of this condition of the general 
system, which, if allowed to continue, might hazard the patient's 
safety. Dr. Bateman once met with a case of this kind, where the 
fading efflorescence became mixed with petechias, and as there was 
apparently no local congestion, the decoction of cinchona with sul- 
phuric acid and a little wine were administered, and the child 
speedily recovered. 

Treatment of Malignant Measles. — When the disease pre- 
sents this type, the mortality will be great under any plan of treat- 
ment. We believe that it is essential to seize the earliest oppor- 
tunity of relieving the congested organs by a small bleeding, if the 
age and powers of the patient admit of loss of blood. The period 
when venesection may be employed quickly vanishes; typhoid fever 
supervening, the practitioner is restricted to local abstraction of 
blood. A nutritious diet, with the use of diffusible stimulants, as 
wine or ammonia, may be advantageously combined with depletion. 
If the typhoid symptoms be not urgent, but insidious pneumonia. 
or bronchitis, or gastro-enteritis, continue, they must be treated on 
the same principles as would guide the practitioner in the manage- 
ment of similar complications arising in common continued fever. 



35 



546 



CHAPTER XII. 



SCARLET FEVER. 



[Syn. — Scarlatina, Morbus scarlatinosus, Febris scarlatinosa, F. rubra, F. scarlatina, 
Morbilli confluentes, M. ignei, Ignus sacer ; Scarlatine, Fievre rouge, Fievre pourpree, 
Fr.; Scharlachfieber , Germ.] 

The term (Scwlatina), for which there is no classical authority, 
appears to have been introduced into medical literature by Syden- 
ham, A. D. 1670, and adopted by Morton and subsequent authors. 

Scarlet Fever, or Scarlatina, is a febrile disease of a contagious 
nature, characterized by scarlet efflorescence of the skin and of the 
mucous membrane of the fauces, generally commencing about the 
second day of the fever, and declining about the fifth, being in most 
cases accompanied by inflammation of the throat, and occasionally 
of the submaxillary glands. 

There is considerable difference in the type of the fever, which 
precedes and accompanies the eruption, which not only modifies 
the disease in individual cases, but influences also the general cha- 
racter of epidemics. Sometimes the febrile excitement is so slight, 
as to be scarcely perceptible ; at others all the symptoms of active 
inflammatory fever are present ; while it sometimes happens, that 
an epidemic has been stamped throughout by fever of a typhoid or 
malignant form. 

The varying character of scarlet fever in different epidemics may, 
in some measure, account for the confusion which prevailed on this 
subject before the time of Sydenham, who had evidently witnessed 
its mildest forms only. Cases of a more severe description were 
certainly observed by Morton (Be Morbillis et Febre Scarlatina), 
who regarded them as an aggravated species of measles, in which 
the eruption had assumed a confluent form. Subsequent authors 
continued to maintain the identity of scarlatina and measles, until 
the comprehensive description of scarlet fever by Dr. Withering 
and Dr. Willan appeared. 



I. VARIETIES. 

There are several forms of scarlet fever, each of which requires 
a separate description. It has already been stated, that the poison 
of scarlatina usually exhibits its effects upon two membranes; 
namely, on the skin and the mucous membrane of the fauces ; to 
one or other of which, however, its action may be restricted. 



VARIETIES. 547 

Hence arise the varieties of scarlet fever, in accordance with a well- 
established law of the action of other poisons, " that they may ex- 
haust themselves on one or more of the tissues they usually affect, 
without involving the whole series ; and that they act with greater 
or less intensity according to the peculiar idiosyncrasy of the pa- 
tient." (Dr. R. Williams, Elements of Medicine, vol. i. p. 131.) 

In the most simple form of scarlatina the fever is seldom of an 
active kind ; the cutaneous efflorescence appears in the usual man- 
ner, but there is no inflammation of the mucous membrane of the 
throat [scarlatina simplex). 

In the second there is greater febrile excitement, and the general 
symptoms are further complicated by inflammation of the fauces 
[Scarlatina anginosa). 

In the third the symptoms are of a more severe description. The 
fever, which is of a typhoid type, with great depression of the vital 
powers, is sometimes accompanied with diphtheritis, or sometimes 
with gangrenous imflammation of the throat, and generally with 
tumefaction of the parotid and cervical glands, and acrimonious 
discharge from the nostrils and ears [Scarlatina maligna). 

In a fourth variety the efflorescence does not appear upon the 
skin, but is confined to the mucous membrane of the mouth and 
throat. Although this form has not been described by Dr. Willan 
as a distinct variety, it was often witnessed by him. [On Cuta- 
neous Diseases, p. 273.) Dr. Tweedie, in his valuable essay on 
scarlatina, [Cyc. Pract. Med.,) has designated this variety Scarla- 
tina faucium. Dr. Williams [op. cit.) has described it as Scarla- 
tina sine eruptione. 



A. SCARLATINA SIMPLEX. 

This variety commences with the ordinary precursory symptoms 
of fever — cold chills, shivering, nausea and sometimes vomiting, 
succeeded by hot skin, frequent pulse, and thirst. In some cases 
the febrile disturbance is so trivial, as scarcely to be noticed ; in 
others it is severe, the prostration becomes great, the pulse rises in 
rapidity, the heat of skin is pungent, and the headache is some- 
times accompanied with transient delirium. 

Some discrepancy of opinion prevails among authors respecting 
the period at which the efflorescence begins to appear. Heberden 
asserts that it is visible on the first or second day. According to 
Willan [op. cit. p. 255), numerous patches of a vivid red colour 
appear about, the face and neck on the second day : while Cullen 
states that it is deferred until the third or fourth day. Another 
more recent and careful observer, Dr. Tweedie, makes the follow- 
ing judicious remarks on this subject : — " It is probable that in the 
majority of instances, the rash comes out on the second day of the 
fever ; and that in cases in which it appears sooner or later, there is 



548 SCARLET FEVER. 

some peculiarity in the individual or the disease to account for the 
variation." In cases in which we have had an opportunity of 
observing the disease from the commencement, the eruption has 
been visible on the face on the second day of the illness. 

The rash at its commencement is perceptible on the face, neck, 
and breast, but gradually extends itself over the trunk and limbs, 
so that generally, after twenty-four hours, the whole body is covered 
with the eruption. The efflorescence consists at first of innumerable 
red points or spots, separated by interstices of skin of the natural 
colour. These small spots quickly coalesce, so that, in the course 
of a few hours, the redness is pretty generally diffused. 

On the face, neck, and upper extremities, the efflorescence is 
uniform and continuous ; but over the trunk it is diffused in large, 
irregular patches. It is of a more vivid hue on the loins, nates 
and the flexures of the joints, than in other parts of the body. 

The efflorescence is often accompanied with a perceptible rough- 
ness, which is most evident upon the extremities and front of the 
body, giving a sensation as if the skin were covered with granules. 
It arises from enlargement of the cutaneous papillse, and has the 
appearance of papular eruption. Where the congestion of the 
cutaneous vessels is very intense, and particularly where the pa- 
tient has been subjected to a heating regimen during the treatment, 
small miliary vesicles occasionally appear on different parts, more 
frequently on the trunk. The rash on the fifth day generally begins 
to decline, the scarlet hue becoming gradually more pale; on the 
sixth day its appearance is very indistinct, and it is wholly gone 
before the eighth day. 

About the fourth or fifth day of the efflorescence, an eruption of 
semi-globular vesicles, containing a thin pearl-coloured serum, has 
been occasionally observed about the forehead, neck, chest, shoul- 
ders, and extremities. They vary in size, and succeed one another 
without determinate order. When punctured they are sometimes 
found empty, or nearly so, the fluid having been absorbed. 

The occasional appearance of these vesicles at the acme, and 
during the decline of the efflorescence of scarlet fever, has been 
noticed by Withering, Willan, Rush [Med. Obs. and Inq.) and 
others. Vogel, Burserius, and Sauvages, from their occasional 
appearance, attempted to establish another variety of this disease, 
under the name of Scarlatina pustularis variolosa. We have 
seen cases in which this secondary eruption of vesicles closely 
resembled varicella in the form of the vesicles, and in the irregu- 
larity of their succession. Similar phenomena are occasionally 
observed in the other exanthemata : they probably depend upon 
the degree of congestion of the cutaneous capillaries in different 
cases. 

The efflorescence in the scarlatina simplex commonly terminates 
by desquamation of the cuticle, which begins about the end of the 
fifth day on those parts where the eruption first appeared, and 



VARIETIES. 549 

gradually proceeds over the body in the same order as the rash 
came out. The desquamation from the face, neck and trunk, is 
usually in the form of scurf; while large portions of cuticle are 
detached from the hands and feet: occasionally the cuticle of the 
palm of the hand, or sole of the foot, is separated entire. 

Such is the ordinary progress of the efflorescence on the surface of 
the body : but the mucous membrane of the mouth, fauces and nos- 
trils, is generally more or less affected at the same time ; the lips, the 
edges of the tongue, the soft palate, the pharynx, the nostrils, and 
even the internal surface of the eyelids, being of a bright red colour. 
The papillae of the tongue become considerably elongated, their 
red points projecting through the thick mucus which covers its 
surface ; when that organ is clean, or morbidly red, the elongated, 
enlarged, and deep scarlet papillae give it a very characteristic ap- 
pearance. 

The affection of the mucous membrane of the mouth and fauces, 
which is not constant in the scarlatina simplex, terminates by reso- 
lution ; and with the disappearance of the rash the febrile symptoms 
subside, the disease terminating at the end of a week, though it 
often leaves the patient in a state of considerable debility. 



B. SCARLATINA ANGINOSA. 

In this variety the precursory symptoms are more violent than 
in the preceding. In some cases the first symptom is sudden stiff- 
ness of the muscles of the throat and angles of the jaw, accompa- 
nied by uneasiness in swallowing, which on the second day becomes 
more painful and difficult, the sufferings of the patient being rendered 
more distressing by constant efforts to expel a viscid secretion from 
the mucous crypt of the tonsils and pharynx. Upon examining 
the throat, there is considerable swelling of the tonsils, uvula, and 
soft palate, with florid redness of their surface, which extends to 
the posterior part of the fauces. In severe cases small patches of 
a darker hue are observed on the inflamed membrane, at which 
points there is often an exudation of a coagulable lymph, of a gray- 
ish-white appearance, which, unless examined with care, may be 
mistaken for sloughs of the mucous lining ; but by directing the 
patient to clean his throat by means of a gargle, by which this 
exudation may be removed, the mucous membrane will be found 
entire, and free from any loss of substance. These crusts of lymph, 
which are renewed from time to time, extend, according to Rayer, 
( Traite des Maladies de la Peau,) into the lateral parts of the 
pharynx and oesophagus, but not into the larynx or trachea. This 
coincides with the observation of Dr. Tweedie, who states that in 
the dissections of scarlatina anginosa which he has made, he has 
not seen an instance of membranous exudation extending to the 
larynx. 



550 SCARLET FEVER. 

In some cases the fever precedes or accompanies the sore throat; 
in others it is delayed until the appearance of the efflorescence. It 
is generally, from its commencement, of a more active kind than in 
scarlatina simplex, indicating a severer form of disease. On the 
second or third day, as the inflammation of the throat becomes more 
urgent, there is generally a considerable increase of the febrile ex- 
citement; the debility is greater; the pulse more frequent and of 
unequal strength; the respiration oppressed; the temperature of 
the skin rises to 106° or 108°, sometimes to 112°; there is urgent 
thirst; and the tongue, especially at its tip and edges, assumes a 
scarlet hue, while its papillae are much enlarged. As the evening 
approaches, there is an exacerbation of fever with extreme restless- 
ness, and often delirium, during the night. 

In this variety, the efflorescence does not observe the same regu- 
larity as in the scarlatina simplex. It does not appear so early, but 
is often delayed to the third or fourth day, and generally comes out 
in scattered patches on the chest and arms. In some cases it is 
entirely confined to the back of the hands and wrists, and some- 
times wholly vanishes the day after its appearance, and reappears 
partially at uncertain times, so that its whole duration is longer than 
in scarlatina simplex. About the fifth or sixth day it begins to grow 
sensibly paler, following the same order in its decline which it had 
previously observed on its appearance, subsiding first on those parts 
which it had primarily occupied. Desquamation of the cuticle 
frequently follows the disappearance of the rash, though this is by 
no means an uniform occurrence, seeming in some measure to 
depend on the intensity or duration of the previous eruption ; for 
when the latter has been slight and of an evanescent character, 
desquamation seldom follows. 

The fever and inflammation of the throat begin to abate with 
the fading of the eruption, though sometimes the sore throat and 
some degree of fever continue for a week or ten days after the rash 
has entirely disappeared. 

The above description is intended to apply to scarlatina anginosa, 
as it is usually observed. It sometimes, however, assumes an ag- 
gravated form ; thus, in addition to the symptoms already enume- 
rated, there is sometimes acrid discharge from the nostrils and ears, 
frequently accompanied with deafness or inflammation of the parotid 
and cervical glands, terminating in suppuration of the cellular tis- 
sue. But although these occasional complications tend to keep up 
the febrile excitement, and to prolong the duration of the disease, 
they do not materially add to the danger, as they generally subside 
in a few days after the disappearance of the more characteristic 
symptoms of the disease. 

During the progress of scarlatina, the attention of the practi- 
tioner should be constantly directed to the state of the internal 
organs. Dr. Tweedie, in enumerating the complications of scarla- 
tina, directs attention particularly to the great disposition to inflam- 



VARIETIES. 551 

mations of the serous membranes ; so that, when an organ becomes 
inflamed during the progress of scarlet fever, the serous membrane 
is much more generally the seat of inflammation than the paren- 
chyma. There are few practitioners who have had much experi- 
ence of scarlet fever, who have not had cause to lament the loss of 
patients from meningeal, pleuritic, or peritoneal inflammation. 



C. SCARLATINA MALIGNA. 

This variety, proposed by Dr. Will an and adopted by subsequent 
writers, was described by Cullen under the title of Cynanche 
maligna. A reference to his description will all at once show that 
he described a severe form of scarlatina. Dr. Fothergill, in his 
Jiccount of the Sore-throat attended with Ulcers, which prevailed 
as an epidemic in London in the years 1747-S, has also described 
this malignant form of scarlatina ; and the epidemic which prevailed 
from 1751 to 1753, of which Dr. Huxham has given an account, 
(On Fevers and Sore-throat,) was undoubtedly the scarlatina 
maligna of Willan : indeed, in his Essay on the Malignant Ul- 
cerous Sore-throat, he admits its great resemblance to scarlatina 
anginosa ; and that "truly some of the scarlet fevers mentioned by 
Morton were not much unlike it." 

Although at its commencement the symptoms of scarlatina ma- 
ligna differ little from those of the scarlatina anginosa, yet at an 
early period its formidable nature becomes apparent. Thus the 
fever assumes a typhoid form, the heat of skin is less intense, and 
there is great disorder of the functions of the sensorium, with small, 
frequent, and often irregular pulse. There is at the same time dull 
redness of the eyes, with a dark red flush on the cheeks ; the patient 
is restless, fretful, and at times delirious ; the delirium is sometimes 
violent, but more generally it is of the low muttering kind. The 
tongue quickly becomes dry and brown, or red, dry and glazed, and 
often so tender and chapped, that a slight touch causes it to bleed ; 
the teeth and lips are covered with sordes, and the odour of the 
breath is extremely fetid. The throat lias a dusky red appearance ; 
there is not much swelling, but dark incrustations form on the 
velum, uvula and tonsils, which are not, as has been generally sup- 
posed, sloughs, but merely exudations of lymph or false membranes. 
In some cases, however, there is gangrenous inflammation of these 
parts, which are destroyed by the sloughing which succeeds. There 
is, at the same time, acrid excoriating discharge from the nostrils, 
and a viscid secretion from the fauces, impeding respiration and 
producing a rattling noise. The inflammation in severe cases 
spreads to the posterior pharynx, which, though not much swollen, 
is so irritable, that on attempts to swallow fluids they are rejected 
through the nostrils. The inside of the lips and cheeks is frequently 
covered with aphthae, and the cervical and submaxillary glands 



552 SCARLET FEVER. 

become inflamed, abscesses occasionally forming in the surrounding 
cellular tissue. 

The rash is extremely irregular as to the time of its appearance 
and duration. It often comes out at a late period of the disease, 
and disappears after a few hours ; or it vanishes suddenly, and is 
again renewed several times in the course of the disorder. Its 
colour is generally paler than in the other varieties, except that here 
and there, in irregular patches, it assumes a deeper hue. In some 
cases there is great tendency to hemorrhage from the mucous sur- 
faces, either from the nostrils or throat, intestines or urinary canals; 
petechias often appear upon the skin and the patient gradually sinks, 
unless the constitution has been previously very vigorous. Dr. 
Tweedie has, in a few instances, seen the large joints become ex- 
tremely painful and swollen with evidence of fluctuation ; the patient 
is generally destroyed in a very short time. Patients who withstand 
the violence of the early symptoms, have often to struggle against 
a series of most untoward circumstances for a considerable time. 
Some die from exhausting diarrhoea; others sink suddenly and 
unexpectedly, after giving hope of recovery ; sometimes death takes 
place from the supervention of serous inflammation and its conse- 
quences. Even when scarlatina at its onset has been of the mildest 
form, it sometimes happens that its whole aspect becomes suddenly 
changed, and the symptoms assume a malignant character; and 
when the disease is epidemic, it often exhibits, in different persons 
of the same family, every gradation from the slightest to the most 
malignant form of the disease. 

In many instances this malignant variety of scarlatina terminates 
fatally on the third or fourth day, and Dr. Willan says, "as early 
as the second day, no symptoms having preceded which could 
excite an apprehension of immediate danger." In the severe epi- 
demic described by Dr. Withering, similar instances are recorded. 
Dr. Tweedie describes cases terminating fatally" on the second, 
third, or fourth day, without the practitioner being able to assign 
any satisfactory reason, or discover any lesion on the most careful 
examination of the body." These opinions are confirmed by the 
observations of Mr. Hamilton (Edin. Med. and Surg. Jouryi., 
vol. xxxix.), and by Dr. Sandwith, in his account of the'Bridling- 
ton epidemic. Dr. Willan has justly remarked, that in cases ter- 
minating fatally so soon after the accession of the fever, the throat 
has probably been longer affected, and that the poison had gradually 
pervaded the whole constitution; hence the sickness, shiverings, 
languor, delirium, and coma, do not, in such instances, denote the 
commencement of the fever, but are the final symptoms of an insidi- 
ous and most virulent distemper. We have met with a few cases 
of this description which terminated rapidly with oedema of the face 
and profound coma. 



SEQUELS. 553 



D. SCARLATINA SINE EXANTHEMATE. 

In this form, the specific action of the poison is limited to the 
mucous lining of the mouth and fauces, the scarlet efflorescence of 
the skin being wanting. Cases of this description frequently occur 
when the disease prevails epidemically. It was the opinion of Dr. 
Willan, that this complaint was peculiar to adults; we have, how- 
ever, known a case in a child of five years, which terminated 
fatally. 

When scarlatina exists as an epidemic, this variety is sometimes 
observed simultaneously with the other forms of the disease in 
individuals of the same family. Dr. Willan contends, that " it is 
evidently a species of scarlatina, because it affects some individuals 
of large families, while the rest are labouring under other forms of 
scarlatina, and because it is capable of communicating by infec- 
tion all the varieties of that disease" The author has had good 
opportunities of confirming this opinion of Dr. Willan. The same 
learned writer thus continues, " Persons who have previously gone 
through the scarlatina anginosa, experience, while conversant with 
the sick, very uneasy sensations in the throat ; in some there is an 
inflammation and swelling, or ulceration, of the tonsils, producing 
considerable pain and irritation, but without the specific fever and 
efflorescence." Dr. Johnstone, in his description of the epidemic 
which prevailed at Worcester in 1778, states, that while some indi- 
viduals at the first seizure were covered with the scarlet efflo- 
rescence, others of the same household had the ulcerated throat 
without any eruption of the skin ; and that in some instances, 
patients suffering from anginose inflammation without the rash, 
have communicated the disorder to others, in whom it has appeared 
as an eruptive disease. Dr. Tweedie has recorded similar instances. 
"It may appear singular/' says Dr. Willan, "that one of the 
slightest of the eruptive fevers and one of the most violent, that 
epidemics which vary as much in fatality as a flea-bite and the 
plague, should be associated together and spring from the same 
origin. Experience, however, decides that the scarlatina simplex, 
the anginosa, the maligna, and the scarlet sore-throat without the 
efflorescence on the skin, are merely varieties of the same disease ; 
and that all of them proceed from the same source of contagion." 



II. SEQUELS. 

It often happens, when scarlatina is apparently advancing to- 
wards a favourable termination, that recovery is retarded, and 
sometimes even life destroyed, by the supervention of certain local 
affections, which are to be regarded as accidental complications or 
sequelae. Some of these have already been adverted to. The 



554 SCARLET FEVER. 

great tendency to inflammation of the pleura, peritoneum, and more 
rarely of the arachnoid and pericardium, in the course or during the 
decline of the fever, has been mentioned. In certain epidemics, 
moreover, the disease is prolonged, and its mortality increased by 
the supervention of bronchitis or gastro-enteritis. More rarely still 
the disease is followed by purulent deposits in the large joints, or 
by gangrene of some portions of the extremities. 

[Dr. Golding Bird states that he has witnessed in a few cases a 
rather anomalous set of symptoms following scarlatina, and. accom- 
panied, in at least two instances, by coagulable urine without ana- 
sarca. These appeared referrible to peculiar pains, at first sight, 
apparently, of a rheumatic character, limited almost entirely to the 
lower limbs. As, in all these cases, the patients were young chil- 
dren, it was difficult to form a correct notion of the character of the 
pain. There was no tumefaction or redness of the joints, nor much 
pain evident on pressing or moving the limbs ; the little patient 
merely crying out frequently with "pain" in the legs, which, from 
its occurring in paroxysms, and not being constant, appeared to be 
of a spasmodic or cramp-like character. These symptoms all yielded 
to the warm-bath, antimonials, and sometimes to a little iodide of 
potassium.]* 

Dropsy is an occasional consequence of scarlatina. It occurs 
more frequently in the form of anasarca of the face, eyelids, and 
lower extremities ; but occasionally becomes general. Sometimes 
the effusion takes place in the different serous cavities ; and, when 
this happens, the result is very doubtful. Dropsy succeeding to 
scarlatina is noticed by many writers, who appear to have arrived 
at very different conclusions as to its importance ; Morton, the first 
English author who has given a full account of scarlatina, notices 
it, and evidently regarded it as of serious import. ( Op. cit., cap. iv.) 

In the account of scarlatina, as it prevailed at Vienna in 1762, 
Plenciz states, that the dropsy which succeeded the disease was 
more dangerous than the primary fever. (Willan, p. 235.) Drs. 
Sims and Wells, however, who published histories of the epidemic 
scarlatina of 1786, appear to think anasarca a symptom of trifling 
importance. ( Trans, of Soc. for the Imp. of Med. and Surg. 
Knowledge, vol. iii.) Cullen, Bateman, and Armstrong, pass 
over this complication with slight notice. Dr. Blackall ( Observa- 
tions on Dropsies) first observed the albuminous state of the urine 
in many of these cases ; and the subject has recently acquired fresh 
interest and importance by the discovery of Dr. Bright, that albu- 
minous urine is frequently associated with structural changes in 
the kidneys. It is singular that the dropsy has been remarked to 
succeed to the mild as often as to the severe forms of the disease ; 
and that it has never been observed to supervene in cases of scarla- 
tina maligna. Children are much more frequently attacked than 
adults, but it is more common in the latter than is usually supposed. 

* [Gut's Hospital Reports, April, 1845, p. 138.] 



SEQUELS. 555 

It generally comes on in ten or twelve days from the disappearance 
of the rash, but sometimes earlier and sometimes later. Its ap- 
proach is generally announced by paleness of the countenance, a 
leucophlegmatic aspect, increasing languor, loss of appetite, furred 
tongue, costive bowels, scanty and turbid urine, and often consi- 
derable gastric disturbance. The swelling more frequently begins 
on the face and hands, to which it maybe confined; but in general 
it extends till the whole body becomes oedematous. There is but 
little to be apprehended so long as the serous effusion is confined to 
the subcutaneous cellular tissue ; but when it takes place in the 
cavities, the danger is imminent. When the fluid is effused into 
the ventricles of the brain, the swelling of other parts of the body 
often partially subsides. Drowsiness, coma, and convulsions super- 
vene, which generally prove fatal. Another source of danger is the 
rapid accumulation of fluid in the chest, which is commonly pre- 
ceded for some time by general anasarca, and the suddenness of the 
effusion is in some cases remarkable. As serous effusions are to be 
regarded as secondary affections resulting from some previous 
morbid action, it is of importance to ascertain their cause. On this 
subject Dr. Blackall remarks, " There is something hitherto ob- 
scure in the disposition to cedema which scarlatina leaves. The 
time, the symptoms, and the subjects of this attack, by no means 
permit the opinion that it originates in mere debility. On the con- 
trary, the attendants are often persuaded that the patient has caught 
some fresh cold ; and it is certainly not improbable, that the previous 
inflammation and irritation of the skin may be followed by an op- 
posite state of it, incapable of supporting even the common changes 
of temperature. " 

Dr. Tweedie regards the dropsy as arising from increased action 
in the sanguiferous system. That this is the cause of the effusion, 
if not invariably at least in the majority of instances, and certainly 
in all those which have come under his observation, was evident 
from the character of the pulse as to frequency and power, the 
coagulable urine, the rapidity with which the fluid accumulated (if 
not arrested by prompt treatment), and from the efficacy of blood- 
letting, purging, and other antiphlogistic measures, which were 
generally necessary to remove the dropsical effusion. We fully 
coincide in the opinions of these two practical physicians. Mr. 
Hamilton has attempted to show that the kidneys exhibit traces 
of commencing disorganization, and thus to account for the dropsy 
and albuminous urine. (Edin. Med. and Surg. Journ., vol. xxxix.) 
But it is now well known, that the albuminous urine may be secreted 
where the structure of the kidney is healthy ; and no instance is 
known of recovery from dropsy with granular degeneration of the 
kidney, but recovery from dropsy after scarlatina is frequent. 

[Scarlet fever being essentially a blood-disease, the effects of the 
poison, as has been justly observed by Dr. Golding Bird,* is a 

* [Gut's Hospital Reports, April, 1845, p. 136.] 



556 SCARLET FEVER. 

determination of blood towards the cutaneous and mucous surfaces, 
shown by the characteristic rash covering the one, and the ery thismic 
state of the other, many of the glandular structures partaking of 
this congestion. If the eruption is fully developed, the effects of the 
poison become exhausted. But if the effects of the scarlatinal poison 
are interfered with by any irregularity in the cutaneous affection, 
the poison not being completely eliminated, some of the recognized 
after effects result. 

"In what manner," Dr. Bird inquires, "does the presumed relict 
of scarlatinal poison act in producing the peculiar after effects of 
the disease ? Granting, then, the existence of an imperfectly ex- 
hausted materies morbi in the blood after the disappearance of the 
incompletely-developed exanthem, attempts will be made to excrete 
this matter, under some form or other, by one of the different emunc- 
tories of the body. That the skin is adequate to this task is rendered 
probable by the fact before alluded to, of the extreme rarity of scar- 
latinal anasarca in those cases in which a perspirable, or at least 
freely exfoliating state of surface has been obtained within a few 
days after the recession of the rash on the skin. When the deter- 
mination of blood to the cutaneous capillaries has not been sufficient 
to allow of the excretion of the poison by the skin, or when it has 
experienced the astringent influence of cold, or perhaps even of 
inattention to cleanliness by the omission of frequent ablutions of 
warm water, an attempt is made to get rid of the relict of the disease 
by some other outlet. From the researches of Wohler and others, 
with which the profession is perfectly familiar, it seems demonstra- 
ble, that, as a general rule, all effete matters existing in solution in 
the animal fluids are excreted by the kidneys. Accordingly, a large 
supply of blood is sent to these organs, their capillaries become 
dilated, and congestion occurs. The almost necessary result of this 
pathological condition of the kidneys is a double lesion of their 
function. An exudation of the albuminous elements of the blood 
occurs, and renders the urine coagulable, its tint being often dark- 
ened by an admixture of red particles ; whilst, on the other hand, 
the kidneys cannot carry on their important depurating functions 
perfectly, they eliminate but imperfectly the nitrogenized effete 
elements of the blood, and hence one or more of the normal con- 
stituents of the urine are detectable by chemical analysis in the cir- 
culating mass. Cotemporaneously with these lesions, more or less 
effusion into the loose subcutaneous cellular tissue, to a varying 
amount, generally but not necessarily occurs." 

Dr. Bird expresses his conviction that the train of effects following 
scarlet fever is due to the retention of the nitrogenized elements 
of urine in the blood. This conclusion, he thinks, is justified by 
the analogy existing between the disease under consideration and 
albuminuria, in which the existence of effete nitrogenized matter in 
the blood is, at least in several of its phases, a necessary accompani- 
ment. The recognizable sequela? of scarlatina referrible to this 



STATE OF THE BLOOD, 557 

category are characterized by a tendency to the supervention of 
serous inflammation, particularly of the pleura, arachnoid, and peri- 
cardium. Besides insidious arachnitis, there is another form of 
head affection of occasional occurrence, closely resembling that 
pointed out by Dr. Bright as peculiar to albuminuria — a state cha- 
racterized by the occurrence of quiet stupor, or epileptiform convul- 
sions, generally ending fatally. Several cases of this kind were 
published by Dr. Bird some years since.* Pericarditis is by no 
means an unfrequent complication of scarlatina. Dr. Bird states 
that scarcely a month passes over that he does not meet with cases 
of heart-disease consecutive to pericarditis following scarlatina. 
Many of the best authorities on the practice of medicine, however, 
make no mention of pericarditis as a complication of scarlet fever ; 
and Dr. Watson observes, that the affections of the joints similative 
of rheumatism, occurring in the course of scarlatina, may be distin- 
guished from true rheumatism by the absence of cardiac implica- 
tion.! But on the other hand, MM. Rilliet and Barthez, Drs. 
Joy,J Robert Willis,§ Copland, Professor Von Ammon, of Dres- 
den, || Puchelt, and more recently Dr. Scott Alison,1F confirm the 
statement of Dr. Bird. Dr. Alison's paper, especially, is highly 
interesting and satisfactory, being accompanied by several illustra- 
tive cases.] 



[III. STATE OF THE BLOOD. 

Andral and Gavarret have made four analyses of the blood of 
three persons suffering from scarlatina. Two of these analyses de- 
cidedly indicate the character of hypinosis, although not in a very 
marked degree. The two other cases present differences which will 
be presently explained. 



Venesection. 


Water. 


Fibrin. 


Blood-corpus 


cles. 


Residue of serum . 


1st Case j g 


761-5 


31 


146-0 




89-4 


782-6 


4-0 


124-3 




89-1 


2d " 1 


776-3 


3-5 


1361 




84-1 


3d " 1 


798-3 


6-8 


112-2 




82-7 



The first bleeding in the first case was ordered on the second day 
of the eruption ; the second during convalescence. At this period 
a number of boils had appeared, and there was considerable fever, 
to which two circumstances the change in the blood is attributable. 

The bleeding in the second case was ordered on the second day 
of the eruption. 

* [London Medical Gazette, June, 1840, p. 432.] 

f [Watson's Practice of Physic, 2d Am. ed. p. 1031.] 

i [Library of Practical Medicine, 2d Am. ed., vol. ii. p. 524.] 

§ [London and Edinburgh Journal of Medical Science, No. X.] 

1 [Analekten iiber Kinder Krankheiten. Stuttgart, 1837.] 

i [London Medical Gazette, Feb. 1845, p. 664.] 



558 SCARLET FEVER. 

Lecanu* has also made two analyses of the blood in this disease, 
and has obtained nearly similar results. 





Biood of a man 


Blood of a man 




aged 35 years. 


aged IS years. 


Water 


776-55 


770-41 


Blood-corpuscles - 


144-55 


146-80 


Residue of serum 


78-90 


82-70 



The quantity of fibrin was not determined by Lecanu.] 



IV. ANATOMICAL CHARACTERS. 

The morbid appearances on the dissection of fatal cases of scar- 
latina are by no means uniform. Dr. Tweedie states, that he has 
frequently been surprised, in examining rapidly fatal cases, to find 
no morbid appearances that could explain the cause of death : in 
such instances, it is more than probable, that the diseased condition 
of the blood and fluids has had an important share in the fatal 
issue. The most uniform specific action of the poison during life 
is upon the skin, producing the exanthema or rash ; but as this con- 
sists simply of intense congestion of the cutaneous capillaries, it 
speedily vanishes after death. The skin in some places is florid, 
of a dark red colour ; and in others there are livid spots and pete- 
chias, these latter being produced by extravasation of blood into 
the cutaneous and subcutaneous cellular tissue. In fatal cases of 
scarlatina anginosa, dissection often reveals a congested state of the 
mouth and pharynx. These organs exhibit a deep red tinge, which 
in some instances extends to the trachea and bronchi : there is gene- 
rally swelling of the tonsils and the adjacent parts, which are fre- 
quently covered with coagulable lymph. In scarlatina maligna, 
however, these appearances are not observed, or at least, the tume- 
faction of the throat is generally trivial ; but the lining membrane 
has a dark livid colour, sometimes abraded, and frequently covered 
with exudations of dark-coloured lymph, which have often been 
mistaken for sloughs. It often happens, however, even where the 
inflammation of the throat has been most severe and : distressing 
during life, that no traces of its existence are discoverable after 
death. 

In some epidemics it has been observed, that the inflammation of 
the mucous membrane is much more extensive. In the epidemic 
which prevailed in Edinburgh during the autumn of 1832, described 
by Mr. Hamilton, and wherein he attended 150 patients, almost 
every severe case had more or less of the chest affection ; and he 
mentions only one fatal case, in which it was not evident from the 
appearances after death, that violent inflammation had extended to 
the larynx, trachea, and lungs. {Edin. Med. and Surg. Joarn., 
vol. xxxix. ) 

* [Etudes Chimiques, etc., p. 97.] 



causes. 559 

The abdominal viscera are rarely affected, although occasionally 
the mucous membrane of the intestinal canal is red and injected : 
sometimes the peritoneum exhibits marks of previous inflammation, 
with effusion of fluid into the abdominal cavity. 

[It has been asserted by some recent authorities that the intestinal 
follicles, especially the agminate, are often found to be enlarged 
and inflamed. Dr. Grisolle states that he has never been able to 
verify this statement in any of the autopsies that he has made. 
(See p. 238.)] 

The appearance of the kidneys is not uniform, apparently de- 
pending upon the existence and duration of dropsy. Where patients 
have sunk early in the disease, these organs have generally been 
found healthy ; in protracted cases, they sometimes exhibited a mot- 
tled and granulated appearance. When dropsy had appeared before 
death, Mr. Hamilton [F. Fischer, and Rayer], found the altera- 
tions in the kidneys much more decided, presenting the appearance 
of the first stage of Bright' s disease, the alteration of structure 
being generally in proportion to the duration of the disease. The 
cortical substance, however, never presented, except very slightly 
in one case, the granular appearance seen in the more advanced 
stages of Bright's disease ; nor was the tubular structure ever en- 
croached upon, which is, perhaps, from the recentness of the attack, 
just what we should expect. Should these apparently progressive 
alterations of structure, in cases of dropsy with albuminous urine 
consecutive to scarlatina, be confirmed, the highly probable opinion 
entertained by Dr. Graves will be strengthened, viz., that the mot- 
tled degeneration of the kidney (Bright's disease) is not to be 
regarded as the cause of the secretion of albuminous urine; but, on 
the contrary, that it is the progressive and long-continued faulty 
elimination of albumen with the urine, which produces the gradual 
change in the cortical portion of the kidney. 

When the primary fever has terminated fatally after violent deli- 
rium, Dr. Tweedie has found the arachnoid membrane vascular or 
even opaque, with effusion of a serous or sometimes milky fluid 
underneath: in such cases, the substance of the brain is also con- 
gested. 

When purulent deposits take place in the joints, a morbid condi- 
tion observed in the London Fever Hospital, there are rarely marks 
of inflammation in the synovial membrane. Dr. Tweedie is in- 
clined to think, that the pus deposited in the joints is not the conse- 
quence of inflammatory action, but that it is deposited from the 
blood, in the same manner as is sometimes observed in other parts 
of the body. 

v. CAUSES. 

Epidemic scarlatina occurs more frequently in the autumn 
months after a warm summer, especially when the heat has been 



560 SCARLET FEVER. 

accompanied with continued rains, and when the succeeding winter 
has been open and mild. It generally disappears during the spring 
months, though in some epidemics, it prevails in every month of 
the year. It occurs more frequently in the early than in the ad- 
vanced periods of life, and in females than in males; so that child- 
hood and the female sex appear to be more predisposed to the dis- 
ease than manhood and the male sex. Children and females are 
much more exposed to the influence of the poison than men, and 
perhaps all children are susceptible of the influence of the poison; 
whereas, many adults having passed through the disease in child- 
hood, may be said to be almost exempt from future attacks. 

Dr. Clark has given a tabular view of the cases under his care 
in 1778 and 1779, from which it appears that children under ten 
years of age were most liable to the disease; that under twenty years 
of age, the number of males and females was almost equal; but that 
above this period, the number of females greatly exceeded that of 
the males. (Cited by Willan, p. 344.) Dr. Tweedie has given a 
similar table of cases of scarlatina admitted into the London Fever 
Hospital, from which (omitting the cases under ten years of age, as 
few of that age are admitted into the metropolitan hospitals,) the 
same results are obtained. Of 146 cases given by Dr. Clark, there 
were 66 males and 80 females; and of 184 cases given by Dr. 
Tweedie, there were 55 males and 129 females. It further appears, 
that the susceptibility to the disease diminishes in a very consider- 
able degree after the age of 30 ; for of Dr. Tweedie's cases (184) 
there were only 22 between the ages of 30 and 50. 

Scarlatina appears to be a contagious as well as infectious dis- 
ease. Its contagious nature has been demonstrated by inoculation. 
The serum of the vesicles, which sometimes appears in scarlatina, 
has been used by Sir Busick Harwood, late regius professor of 
physic at Cambridge, and other physicians, to inoculate healthy 
children, in the hope of producing a mild form of the disease. In 
many instances, the disease has been produced, but has proved to be 
as severe as that which occurs spontaneously. (Williams' Ele- 
ments of Medicine, p. 118.) 

The infectious nature of scarlatina is a doctrine scarcely disputed 
in the present day. The rapid spread of the disease in schools, and 
its frequent communication to healthy members of families when 
children have returned home labouring under the disease, or during 
convalescence, though several weeks may have elapsed from the 
period of desquamation, are among the more obvious proofs of its 
infectious nature. It is also the opinion of those who have had much 
experience of this disorder, that clothing, bedding, or furniture of a 
room, which have been used by patients during this disease, are all 
capable of infecting healthy individuals. It was the opinion of Dr. 
Willan, founded upon an experience of 2000 cases, that scarlet 
fever having once run its course, the constitution was afterwards 
insusceptible to a second attack. Exceptions to this supposed law, 



DIAGNOSIS. PROGNOSIS AND MORTALITY. 561 

however, are numerous ; those who have once experienced the 
specific actions of the poison, when exposed to its influence at some 
future period, are not unfrequently attacked with Scarlatina sine 
exanthemata. Sir Gilbert Blane met with an instance of its 
occurring thrice in a young lady, " without the least suspicion of 
ambiguity or possibility of mistake." [Med. Chir. Trans., vol. iii.) 
Analogous instances of the recurrence of small-pox, and other ex- 
anthemata, might be adduced in support of this statement. The 
period which elapses after exposure to the influence of the poison, 
before it produces its specific effects, probably varies from twenty- 
four hours to about ten days. In one case, in which the virus was 
introduced by inoculation, Rostan says, that seven days elapsed be- 
fore the appearance of the eruption. (Clin. Med., torn, ii., p. 206.) 



VI. DIAGNOSIS. 

The only diseases with which scarlatina may be confounded, 
are measles and roseola. From measles it may be distinguished 
by the precursory symptoms ; by the time intervening between the 
first accession of fever, and the appearance of the rash ; by the cha- 
racter of the eruption ; and by the sequelee. Measles commences 
with coryza, sneezing, suffusion of the eyes, cough, slight dyspnoea, 
and other catarrhal symptoms; while in scarlatina, the first sensation 
of uneasiness is referred to the throat. The eruption in measles 
shows itself on the fourth day of the fever, but in scarlatina it may 
usually be distinguished on the second. In measles the rash is dis- 
posed in irregular portions of a crescentic form, and is slightly ele- 
vated, so as to be sensible to the touch ; in scarlatina the eruption 
assumes the appearance of broad patches of an indeterminate shape. 
The rash has a different tint in the two diseases ; it is of a vivid red 
in scarlatina, but of a darker or raspberry hue in measles. In scar- 
latina the fever does not abate upon the appearance of the eruption 
to the same extent as in measles; the former is frequently succeeded 
by anasarca, inflammation of serous membranes, depositions in the 
joints, &c. The sequels of measles are principally affections of the 
respiratory organs, as bronchitis, pneumonia, croup. 

Roseola is distinguished from scarlatina by the partial and regu- 
larly defined rash, by the absence of the angina, by the mildness of 
the febrile disorder, and by the short duration of the complaint. 
Deep rose-coloured patches, exactly like roseola, sometimes appear 
intermixed with the rash of scarlatina. 



vii. prognosis and mortality. 

The only danger to be apprehended in scarlatina simplex is the 
occurrence of some internal local inflammation, or the superven- 
36 



562 SCARLET FEVER. 

tion of anasarca, when the desquamation of the cuticle is completed. 
It must also he borne in mind, when scarlatina prevails epidemi- 
cally, that a mild case sometimes suddenly assumes a malignant 
type. [It should be recollected that the sequelae are much more 
frequent after mild cases of scarlet fever than severe ones. This 
should render a prognosis very guarded.] The prognosis in scar- 
latina anginosa is influenced chiefly by the extent and severity of 
the local inflammation, bearing in mind, however, that there is a 
natural tendency in angina to terminate in resolution. A bright 
florid appearance of the inflamed mucous membrane is a more fa- 
vourable symptom than when it presents a dark livid aspect. But 
if there is excessive tumefaction of the throat and surrounding 
parts, and especially if the inflammation has extended to the air 
tubes, the disease is to be considered dangerous, and will probably 
terminate fatally. In some cases of this kind, oedema of the glottis 
supervenes, and rapidly destroys the patient. The prognosis is 
also unfavourable if the delirium commences, as it frequently does 
in children and young persons, a few hours after the seizure : in 
these cases a fatal result often ensues in the course of two, three, or 
four days. Our prognosis may often be formed from the character 
of the eruption. A bright red efflorescence is more favourable than 
a pale rash, or a dusky red, or one of a raspberry tint. When the 
eruption is partial and evanescent, or when its retrocession takes 
place suddenly at an early stage without reappearing, there is much 
cause for apprehension. Complete desquamation of the cuticle is 
a favourable sign. Scarlatina maligna being always attended with 
great danger, a guarded prognosis should be given. 

Of the circumstances indicating a minor degree of danger, the 
following are the more important. It is generally supposed that 
children withstand the virulence of this disease better than those of 
more advanced age. The absence of visceral inflammation, or of 
structural disease of any important organ, will also lessen the dan- 
ger. A plentiful and florid eruption, a bright red colour of the fauces, 
and a disposition of the exudations on the throat to separate, uni- 
versal desquamation of the cuticle, the pulse falling in frequency 
and rising in power, the breathing becoming gentle and free, the 
countenance resuming its natural expression, and gentle perspira- 
tion, are indications of a favourable result. 

Among the unfavourable signs are the existence of inflammation 
in an important organ, for the subduing of which active remedies 
cannot be employed ; a dark or livid appearance of the eruption, 
more especially when intermixed with petechia? ; the sudden dis- 
appearance of the efflorescence ; a small, frequent pulse, with great 
prostration of strength ; hurried respiration not depending on active 
inflammation of the lungs ; acrid discharges from the nose and 
ears; the admixture of blood in the urine or stools ; involuntary 
evacuations; subsultus tendinum ; hiccough; muttering delirium 



TREATMENT. 563 

and coma ; the appearance of gangrene of those parts subjected to 
pressure, or in the extremities. 

In conclusion it may be remarked, that it is often a fatal disease 
when it attacks pregnant or puerperal women ; and that it is gene- 
rally of a milder character in the spring and summer, than in the 
autumn or winter months. 

Hitherto we have no sufficient data for arriving at any safe con- 
clusions respecting the mortality of scarlet fever. In some epi- 
demics the disease is remarkable for its benign character, scarcely 
affording a single example of a fatal termination ; while in others 
it destroys whole families, and threatens large districts with depopu- 
lation. Sydenham, who had evidently observed the milder forms 
of the disease only, believed scarlet fever so trifling an affection as 
seldom to require medical interference, and that fatal results could 
alone occur from the nimia medici diligentia. Morton, on the 
contrary, having had his attention directed to an epidemic of ex- 
treme violence, is perhaps inclined to overrate the average mortality 
of the disease. A short notice of each of the most important epi- 
demics that have prevailed during the last two centuries will be 
found in Dr. Williams's learned and elaborate work ; and since 
the publication of that work, various monographs have still further 
enlarged our knowledge on this subject. 



VIII. TREATMENT. 

In commencing this branch of our subject, it is necessary to 
mention a point of the utmost practical importance, namely, that 
in every instance the prevailing type or character of the continued 
fever of the period should be taken into consideration, and that the 
treatment found most successful in the latter, should be a guide to 
the practitioner in forming the principles upon which the cure of 
scarlatina should be attempted. 

1. In scarlatina simplex of a mild character but little treatment 
is requisite. The patient's apartment should be kept cool and well 
ventilated. The diet should consist of farinaceous substances and 
cooling drinks; emetics may be given with advantage at the com- 
mencement of the fever. The bowels should be kept open with 
mild aperients. When the heat of the surface is great, patients 
often experience much relief from sponging the body with cold 
water, which is sometimes followed by refreshing sleep. In strong 
and plethoric subjects, when the fever is high, the abstraction of 
blood, either from the arm or locally, may be employed as a pre- 
caution against internal inflammation, which in such cases is always 
to be apprehended. But however mildly this form of the disease 
may commence, it nevertheless requires to be watched, for it is 
surprising how rapidly it is often converted into the more severe 



564 SCARLET FEVER. 

inflammation of an internal organ, or anasarca may supervene 
when least suspected. 

2. In scarlatina anginosa we have distinct local inflammation, 
and fever of a more active type to contend with. The question 
then naturally arises, is a disease attended by such symptoms to be 
treated like other inflammations, by bleeding and other antiphlo- 
gistic remedies? or is there anything specific in the local phenomena 
of scarlatina which requires a modification of such treatment ? The 
solution of this interesting problem must of course be determined 
by a reference to results obtained by eminent physicians from dif- 
ferent methods of treatment. Dr. R. Williams, who has bestowed 
great attention on this point, has drawn up a table of different epi- 
demics which have prevailed from 1763 to 1834; and adds, that 
"the conclusion which inevitably follows is, that the chances of 
recovery are diminished by the practice of bleeding in the ratio of 
nearly four to one, as compared with the chances, supposing the 
patient not to have been bled." From the experience of this dis- 
ease which we have had, we coincide with Dr. Tweedie in the 
statement, that he has "seldom had occasion to bleed from the arm 
unless in particular instances of unusual febrile (or, rather cere- 
bral) excitement, or when some organ was threatened with inflam- 
mation. We generally prefer the free topical abstraction of blood 
by cupping behind the neck, which is the most effectual mode of 
relieving the inflammation of the throat, or by the application of 
leeches under the lower jaw, or behind the ears." Some prefer 
the local abstraction of blood by means of scarification of the ton- 
sils : but this is attended with considerable difficulty in children, 
timid persons, and where the cervical glands are swollen. It may 
be stated, then, as a safe rule, that in a particular epidemic, or in 
some cases, bleeding may be required ; but that in general the state 
of the circulation will not bear bleeding; so that the lancet must 
be employed with the greatest caution, and only upon urgent 
occasions. 

Emetics have been recommended by the best writers on this 
subject. Dr. Withering employed them throughout the primary 
fever and eruptive stage, but it was particularly " at the very first 
attack, and when the throat was more affected ; when the tumefac- 
tion of the fauces was such that the patients could not swallow, 
but with the utmost difficulty," that their good effects were most 
conspicuous. Dr. Willan also employed emetics, but did not find 
it necessary to repeat them so often as Dr. Withering- advises. 
Dr. Burns, who had large experience in the school at Ackworth, 
gave an emetic in almost every case. They are perhaps best em- 
ployed at the beginning of the attack, when the tongue is coated; 
when there is nausea and irritability of stomach ; when the tonsils 
are much swollen, and after local depletion. They are observed to 
be more efficacious in children than adults. 



TREATMENT. 565 

In the last century there appears to have been as much differ- 
ence of opinion on the propriety of employing purgatives as of the 
lancet. Dr. Wlllan says, " Purgatives have nearly the same de- 
bilitating effects as blood-letting; they are indeed very seldom 
necessary. Nevertheless, he thinks the occasional stimulus of a 
small dose, as two or three grains of calomel, very useful." Since 
the profession has tested the importance and practical value of the 
observations of Dr. Hamilton and Mr. Abernethy, there are few- 
practitioners who do not employ purgatives in scarlatina, or any 
other fever, unless they are contra-indicated. There is certainly no 
class of remedies which is entitled to more confidence than purga- 
tives when administered with discretion in the early stages of scar- 
latina. Calomel, in combination with jalap or rhubarb, given at 
night, and a draught of infusion of roses with manna and sulphate 
of magnesia in the morning, will generally be sufficient. Should 
the mucous membrane of the bowels show signs of irritation by 
frequent stools of an unhealthy character, purgatives must be with- 
held and alterative doses of hydrargyrum cum creta with castor oil 
prescribed in their place. In such cases it may be necessary to 
apply a few leeches or a blister to the abdomen, and to restrict the 
patient to a spare farinaceous diet. 

If the patient be much distressd by the excessive heat of skin 
during the continuance of the efflorescence, he will derive not only 
great comfort but advantage from the effusion of cold water over 
the body,'as recommended by the late Dr. Currie, (Med. Rep.,) or by 
simply sponging the body with cold water. The former of these 
methods of allaying the excessive heat is a powerful remedy, either 
for good or evil ; but in consequence of its having been inconsist- 
ently employed and followed by fatal consequences, it has now 
fallen into comparative disuse. All physicians, who have employed 
the latter plan of allaying the distressing heat, are unanimous in 
their opinion of the good effects resulting from sponging with cold 
water, which not only abates the heat, but diminishes the frequency 
of the pulse, allays the thirst, acts as a sedative, often inducing 
sleep and gentle perspiration. 

Although no positive benefits are derived from the employment 
of gargles, still they are sometimes useful in detaching viscid mucus, 
which adheres about the fauces, and in other cases they lubricate 
those parts when there is a deficiency of moisture. Should the 
effort of gargling fatigue or distress the patient, it may be omitted. 
The effervescing saline draught in such cases often refreshes and at 
the same time cleanses the fauces. Dr. Willan, and many practi- 
tioners since his time, have advocated the internal use of chlorine in 
scarlatina : of this remedy the saturated solution of chlorine, recently 
prepared according to the directions of the Dublin Pharmacopceia, 
which contains about twice its volume of chlorine, is the best pre- 
paration. A fluid drachm and a half, with eight ounces of distilled 
water, and two drachms of syrup of lemons, may be taken in divided 



566 SCARLET FEVER. 

portions during the day. For children, ten or twelve drops every 
six or eight hours are a sufficient dose. Of this remedy we have no 
experience ; and those who have employed it have not pointed out 
the particular circumstances when it may be given with most ad- 
vantage. 

When visceral inflammation ensues in the progress of scarlatina, 
vigorous measures should immediately be adopted, although great 
discrimination is required in judging how far the antiphlogistic 
treatment may safely be pursued. 

When the fever has subsided and the cutaneous efflorescence dis- 
appeared, it is often necessary to allow a more nutritious diet, and 
to prescribe tonics. Of these, perhaps the preparations of cinchona 
are the best; and they may be advantageously combined with 
mineral acids. Wine is seldom necessary in scarlatina anginosa, 
unless the disease be protracted and the powers lowered by large 
collections of matter. 

3. The scarlatina maligna, although it commences with local 
symptoms very similar to the preceding variety, quickly indicates 
its formidable nature by the sudden depression of the vital powers. 
If blood-letting from the arm be a remedy of doubtful propriety in 
the two former varieties, it is here hazardous in the extreme. At 
the very onset of the disease the condition of the throat, or fierce 
delirium, may require the application of a few leeches beneath the 
jaw, or the abstraction of a few ounces of blood by cupping from 
the back of the neck : but the local inflammation rapidly assumes a 
malignant form, and typhoid symptoms set in, so that these reme- 
dies must soon be exchanged for a stimulant plan of treatment. 
As the heat of skin is rarely excessive, and the rash very prone to 
disappear, the cold affusion is to be abstained from, and there is 
scarcely necessity for the cold sponging ; even purgatives must be 
administered with great caution, and mercurials given only to the 
extent of regulating the biliary secretions. 

Dr. Bateman was of opinion that, " on the whole, the practice 
of administering gentle emetics appeared to be beneficial in this 
variety, especially at the very onset of the disease." In this opin- 
ion Dr. Tweedie coincides, adding, " unless the powers be so feeble 
as to render the shock of an emetic hazardous, benefit is often de- 
rived from their employment." As the case progresses, the ex- 
treme debility increases ; and the malignant character of the disease 
is so apparent, that all the efforts of the practitioner are directed to 
support the patient's strength by invigorating diet, wine, cordials, 
tonics, and mineral acids. Perhaps of all the tonics the quinine, in 
solution with diluted sulphuric acid, is the most desirable. The 
preparations of cinchona have long enjoyed great celebrity for their 
remedial effects in scarlatina. The use of bark was particularly 
recommended by De Haen, Sauvages, Plenciz, Wall, John- 
ston, Huxham, Cullen, and Percivax, some of whom even 



TREATMENT. 567 

regarded it as a specific cure for scarlatina. Dr. Withering, on 
the other hand, was of opinion that cinchona was often improperly 
administered in scarlatina. Dr. Willan says, (Op. cit., p. 375,) 
". although the bark maybe in many cases useful, it often disap- 
points our expectations ; and when the disease has been improperly 
managed in the beginning, it is wholly inefficacious." 

When the sulphate of quinine is employed in scarlatina maligna 
it should be given in full doses, at intervals of four or six hours; 
and if it does not disturb the stomach, may be persevered in as long 
as the typhoid symptoms continue. Where the quinine disagrees, 
or there is great aversion to its rlavour,port wine, diluted with water, 
or sago, or beef-tea, may be substituted in small quantities at fre- 
quent intervals, with nearly equal good effects. If the pulse con- 
tinue frequent and feeble, the presence of delirium should not pre- 
vent the exhibition of tonics and stimulants. The carbonate of 
ammonia, once highly extolled as a remedy in scarlatina, is often 
prescribed by practitioners of the present day. Various gargles 
have been recommended by different authors, and are more useful 
than in those forms in which there is great internal swelling. Bit- 
ter infusions, as of cinchona, cusparia, or contrayerva, or infusion 
of roses, acidulated with the diluted sulphuric or hydrochloric acids, 
are those most frequently employed: an infusion of capsicum is 
sometimes useful. 

When local inflammations arise in the course of scarlatina ma- 
ligna, general bleeding is rarely admissible ; the practitioner must 
rely upon the topical abstraction of blood by cupping or by the 
application of leeches. Blisters have been much employed with 
the view of relieving the destructive inflammation of the throat, but 
their effects are questionable. Willan says, they are seldom use- 
ful, and sometimes prove injurious. As a general rule blisters are 
better omitted, though they may be useful in particular cases. 

The treatment of the anasarca which ensues after scarlatina, is 
next to be considered. It might be expected that these serous effu- 
sions, which are often the symptoms of constitutional weakness, 
and which follow a disease characterized by great depression of 
strength, would require a stimulating plan of treatment to remove 
them. Experience and examination of fatal cases have proved, 
that these dropsies ought to be treated by antiphlogistic remedies. 
If these cases are treated judiciously before the amount of serous 
effusion is considerable, they are speedily relieved. In all the in- 
stances which have fallen under our notice, there has been manifest 
excitement of the system, indicated by increased frequency and 
hardness of the pulse. In many, where the state of the pulse did. 
not require immediate abstraction of blood, repeated doses of calo- 
mel, followed by some purgative, which excites copious secretions 
from the intestines, have entirely carried off the dropsical effusion. 
In others the activity of the circulation, the hardness of the pulse, 



568 SCARLET FEVER. 

the heat of the skin, oppression of breathing, and scanty urine, have 
suggested the necessity of blood-letting, followed by the administra- 
tion of purgatives and diuretics. When there is suspicion of the 
dropsy depending on renal disease, it is prudent, in addition to the 
other measures, to abstract blood by cupping the loins. Of all the 
diuretics we prefer the combinations of potash with vegetable acids, 
and with these digitalis may often be combined with advantage. 
In children the bitartrate of potash, made into a confection with 
syrup and a few grains of ginger, is a useful remedy in doses of Jss 
to 5j- In some instances where the dropsy comes on in debilitated 
constitutions, or in scrofulous habits, blood-letting maybe dispensed 
with ; and indeed it may be necessary to combine some tonic with 
the purgatives or diuretics. In children the ferri potassio tartras 
may be added to the cream of tartar confection with advantage. 
To the general employment of tonics in this affection, on the suppo- 
sition that the dropsy depends upon debility, we must strongly 
object, inasmuch as it is contrary to our own experience, and that 
of the best practical physicians of the present day. When the effu- 
sions are removed, and all farther danger of inflammation of the 
serous membranes is over, small doses of quinine or salicine, which 
is said by Dr. Williams to be an excellent tonic and diuretic, may 
be given three times a day. These remedies, with a nutritious diet, 
attention to the bowels, and a change of air from town to the open 
country or seaside, are the best means of removing all the conse- 
quences of scarlatina,and of invigorating the general health. [Blood- 
letting, either general or local, the writer suspects is but rarely needed 
in the treatment of scarlatinal dropsy, which he thinks is generally 
asthenic. In large children and adults, cupping over the loins is 
sometimes of service, but in young children antimonial diaphoretics, 
and the warm bath will in most instances effect a cure. Dr. Gold- 
ing Bird says, that he has never known dropsy to follow scarlatina, 
where warm baths had been employed as soon as desquamation 
commenced. A mild mercurial — the hydrargyrum cum creta — may 
sometimes be advantageously given. Flannel clothing will be found 
an excellent adjuvant in the treatment. A large bran, linseed meal, 
or mush poultice over the loins will often afford great relief. Dr. 
Bird recommends a hot mustard poultice to the loins. The iodide 
of potassium, in bitter infusion, is frequently of great utility after the 
skin begins to act. The anemiated condition so general after the 
disappearance of the dropsy, may be relieved by the administration 
of the tartrate or citrate of iron.] 



IX. PROPHYLAXIS. 

There is no precaution that will prevent the spread of the 
miasmata from the sick person, and consequently the infection of 



PROPHYLAXIS. 569 

children and other persons if they remain exposed to the disease. 
The facts which demonstrate the distance to which the miasmata 
extend around the patient's person and communicate the disease, 
are still wanting ; many recorded statements show, that when this 
disease has once appeared in schools, or other establishments for 
children, no precautions have been sufficient to control the spread of 
the infection. It is proper, however, to notice the supposed powers 
of belladonna in preventing the spread of scarlatina. Hahnemann 
of Leipsic, who was the first to advance this doctrine in 1807, ob- 
served that belladonna, given in small repeated doses, produced 
heat and dryness of the throat, swelling of the submaxillary glands, 
and a cutaneous efflorescence or erythema. He thence inferred 
that this medicine, from its producing symptoms analogous to those 
of scarlatina, might prove a preventive against its infection. Obser- 
vations on this interesting prophylactic measure have subsequently 
been made by Dr. Berndt of Castrin, by Dr. Dusterberg of War- 
berg, Dr. Bekr of Bernberg, by Professor Koreff, Hufeland, and 
Keinzman of Berlin, and they all give testimony, more or less 
strong, as to the efficacy of this narcotic employed for the purposes 
suggested by Hahnemann. The quantity administered is very 
minute. Three grains of the extract of belladonna are to be dis- 
solved in f^j of distilled water ; of this solution three drops are to 
be given twice a day to a child under twelve months old, and one 
drop more for every year above that age. In general no sensible 
effects are produced by these doses, but in some instances it brings 
out an eruption similar to scarlatina. As we have never employed 
belladonna as a prophylactic against scarlatina, we can offer no 
opinion as to its value ; but we have seen pain and redness of the 
fauces, with an efflorescence on the skin of the throat, follow the 
administration of a sixth of a grain three times a day. This subject 
is certainly worthy of the careful examination of those practitioners 
who have the charge of establishments for children, where scarlatina 
has made its appearance. It would not induce the prudent prac- 
titioner to relax in other preventive measures, such as complete 
insulation of the affected, ventilation, cleanliness, [the free use of 
the chlorides,] &c; but as such measures have hitherto generally 
failed in the desired object, there can be no objection to making an 
experiment which, as far as we at present know, is perfectly harm- 
less. More minute details on this subject may be found in Cyc. of 
Prac. Med., art. Scarlatina; Jlrch. G£n. de Med., Juin, 1824; 
Hufeland's Journ. du Prac. Heilkunde, Nov. 1825 ; Rust^ 
Mag az in fur die gesammte Heilkunde, v. xxii. 1, 182. 



570 



CHAPTER XIII. 



PUERPERAL FEVERS. 



On perusing the numerous treatises that have been published 
within the last half century on this highly important class of dis- 
eases, the reader must necessarily be struck with the very extra- 
ordinary differences of opinion amongst the several writers as to 
the history and nature of the disease, the symptoms, mode of treat- 
ment, and the result of the practice adopted. The only point on 
which all seem to be agreed is, its great and striking fatality, and 
that it is one of the most serious, intractable, and destructive mala- 
dies to which puerperal women are liable. 

What is of practical importance in these different histories may be 
easily reconciled, without attributing to any of these authors erro- 
neous statements or wilful perversion. They have each described 
what they saw, fairly and completely, and the same difference of 
opinion as to the nature of the disease exists to the present day. 
The confusion has arisen chiefly from considering that every form 
of fever to which puerperal women are liable is necessarily the 
same, the truth being that they vary in their nature and treatment 
as much as other kinds of fevers. With this precautionary con- 
sideration there can be no reasonable objection to the term "puer- 
peral fevers" which has so often been caviled at and attempted 
to be reformed. All the other names which have been substituted 
are liable to objection, as assuming some particular structure to be 
invariably attacked with disease, whereas the local affection is by 
no means uniform; and hence the term " puerperal peritonitis," 
" peritoneal fever," "inflammation of the uterus and its appen- 
dages in puerperal women," will be apt to mislead. The name 
" puerperal fevers" compromises no opinion ; it does not necessa- 
rily imply the existence of idiopathic puerperal fever, a doctrine 
now so much disputed ; and whatever may be our own view of 
the subject, we beg distinctly to state, that in selecting this name 
we only wish to use one most easily understood and generally re- 
cognized. 

From our own researches into the writings of others, and from 
personal experience, both in private practice and as attached for 
nearly eighteen years to a very large lying-in hospital, we are in- 
clined to doubt the propriety of considering puerperal fever as 
merely symptomatic of local inflammation. But if this were 
admitted, we have records of so great a variety in the seat of the 



PUERPERAL FEVERS. 571 

inflammatory action, as proved upon dissection, that it will be 
found impossible to select any one part as peculiarly affected. We 
find in other fevers a liability to particular local lesions, equally 
varying : the brain, the chest, the mucous membrane of the stom- 
ach and bowels, have been, in different epidemics, the seats of the 
disorganizing process ; but it has been too much the fashion to put 
down all the morbid appearances as exclusively the cause, and 
not the result, of the constitutional affection. In considering puer- 
peral fevers it has long been our conviction, that what has been 
called by Sydenham the constitution of the year, has been too 
much lost sight of. The great difference in the accounts of puer- 
peral fevers by different writers is thus easily explained : — They 
have seen and described epidemics differing in their type, their 
local accompaniments, and their power of being influenced by 
remedies ; and hence, honestly stating exactly what they saw, we 
have an explanation of what would otherwise appear contradic- 
tory. That the fevers of puerperal women are much influenced 
by the character of the other fevers of the season, was strikingly ex- 
emplified in the Westminister Lying-in Hospital during the spring 
of 1838, when some of the fatal cases were attended by petechial 
eruptions precisely similar to the spotted fever, which was so pre- 
valent at that time in the London hospitals. 

In the spring of 1822 puerperal fever existed in the Lying-in 
Hospital in two very different and well-marked forms, at an inter- 
val of about six weeks between the last case of the first epidemic 
and the first case of the second. The early cases were of an active 
inflammatory character ; the peritoneal covering of the uterus and 
intestines was chiefly affected ; the albuminous and serous effu- 
sions in the fatal cases showed a sthenic state of the system : that 
is, the cerum was clear, the coagulable lymph firm and white ; the 
patients bore blood-letting and other active treatment to a great 
extent fairly, and with much advantage ; the blood drawn was 
strongly cupped and highly buffed, and the fatal cases were few. 
Six weeks afterwards a very different epidemic was found to exist. 
The same remedies which had been so beneficial a few weeks be- 
fore were naturally at first tried, but their bad success confirmed 
the sagacious remark of Gooch, that " the effects of remedies form 
not only an essential but the most important part of the history." 
(Gooch on Peritoneal Fevers, p. 35.) The fever was attended 
with marked oppression and debility ; the local pain was compara- 
tively slight; the pulse was extremely rapid from the first, with no 
force, and easily compressible ; in many of the cases purulent de- 
posits took place in the joints and in the calves of the legs, and in 
one case there was destructive inflammation of the eye. On dis- 
section, a quantity of fetid, dark, turbid serum, with loose and soft 
shreds of dirty lymph, was found in the peritoneal cavity, with a 
large collection of highly offensive gas. In some the substance of 
the uterus and ovaries was infiltrated with pus, especially in those 



572 PUERPERAL FEVERS. 

cases where there had been purulent deposits in the limbs. It 
was shortly after these cases occurred, that attention was directed 
by Dr. Marshall Hall to some similar cases of purulent deposit 
and destruction of the eye after parturition, {Med. Chir. Trans., 
vol. xiii. part 1,) and which were the first series of cases published 
in this country of that nature, although some isolated cases had 
been previously noticed, which had been looked on as accidental 
complications. In these two epidemics, so striking a variety of 
character could not fail to attract attention, and we shall shortly 
have occasion to notice others ; and yet Dr. Armstrong quotes 
with approbation the following sentence from Dr. Hulme : — " The 
operations of nature upon the human frame in this disease are the 
same in Britain as in Greece, and continue the same at this day as 
they were above two thousand years ago. This is likewise a 
clear proof of the immutability of puerperal fever." (Armstrong, 
p. 63.) In our opinion the puerperal fevers vary, as other fevers 
do, according to the season, local symptoms, the effects of reme- 
dies, and in the organs affected. We shall not trace the history of 
the numerous epidemics which have been recorded ; but referring 
those who are desirous of acquiring such information to the more 
extended publications on puerperal fever, proceed to give a plain 
and practical account of those forms of the disease which are met 
with in hospitals and private practice, cautioning young prac- 
titioners to reflect, that as these epidemics have already so much 
varied, new varieties may again be found ; and that it is advisa- 
ble, especially for those who have the charge of lying-in hospitals, 
to watch closely and anxiously the first cases of the season, both 
as to the symptoms, and as to the effects of remedies, before de- 
ciding on the character of the disease. A minute and searching 
investigation into the morbid appearances of the fatal cases is no 
less necessary, for there is fair reason to suppose, since the publi- 
cation of the cases of inflammation of the veins, absorbents, and 
muscular structure of the uterus, by Dr. Robert Lee and others, 
that formerly those peculiar affections may have existed and yet 
escaped observation. It is to Dr. Robert Lee that the profession 
in this country is principally indebted for a much more extensive 
and complete investigation into the morbid changes produced in 
the course of this disease. But though agreeing with him to a 
certain point, and not doubting that in many, perhaps most of the 
cases formerly known as the low or malignant form of puerperal 
fever, the fatal symptoms have arisen from disorganizing inflam- 
mation of the deeper seated tissues of the uterus or its appendages, 
or from phlebitis, these changes having been overlooked in dissec- 
tion ; yet Dr. Lee has in our judgment made a material omission, 
and one very common at the present day, in passing over the in- 
fluence of the nervous system in these cases ; the vascular system 
is held to be all in all, everything is inflammation, and the power- 
ful effect of altered nervous energy in the production of disease is 



PUERPERAL FEVERS. 573 

lost sight of. Even the congestive form of fever, as described by 
Dr. Armstrong, and which every one of any extended experience 
must recognize, is but slightly alluded to, and, as it appears to us, 
is not cordially allowed to exist. In Gooch's treatise on peritoneal 
fevers already quoted, several cases are recorded in which death 
ensued after certain symptoms, and in which no morbid appear- 
ances were discovered on dissection. Dr. Lee would reply to this, 
that the examination was not pushed far enough, and that a more 
close inspection must have discovered some of the changes he has 
described. But after Dr. Lee's researches into these subjects were 
known, several cases similar to those related by Gooch, occurring in 
our own practice, and in that of others, convinced us that in these 
something might therefore be found : the most careful search was 
made for morbid alterations of structure in the veins, the absorbents, 
the muscular structure, and the lining membrane of the uterus and 
of the adjacent parts, and nothing could be found to explain the 
cause of death. What Dr. Marshall Hall has denominated the 
"shock" on the nervous system, has been much overlooked, which, 
whilst in itself now and then the immediate cause of death, is much 
more frequently followed by great depression of the nervous sys- 
tem, and ultimately by disease of a more protracted and generally 
fatal character. This condition is familiar to surgeons after severe 
injuries from accident, or after operations, and it is well known that 
patients in the crowded wards of hospitals, or such as have pre- 
viously led dissipated lives, are much the most seriously and rapidly 
affected. 

One of the most interesting portions of Dr. Ferguson's recent 
work, (On Puerperal Fever,) is that detailing his own views of the 
cause of puerperal fever. By a series of arguments, ingeniously 
arranged and cleverly narrated, he endeavours to establish the fol- 
lowing propositions : — 1. The phenomena of puerperal fever origi- 
nate in a vitiation of the fluids. 2. The causes which are capable 
of vitiating the fluids, are particularly rife after childbirth. 3. The 
various forms of puerperal fever depend on this one cause, and may 
be readily deduced from it. He proceeds to show, by enumerating 
various experiments, that the introduction of pus, putrid matter and 
other vitiated substances into the veins, produces lesions of various 
organs, more or less similar to those found in the fatal cases of puer- 
peral fever, and a train of symptoms closely analogous. He then 
points out the condition of the uterus after delivery, and the sepa- 
ration of the placenta ; the bruised condition of the pelvic cavity ; 
the abraded state of the mucous membrane of the uterus, where the 
placenta was attached ; the gaping orifices of the veins and sinu- 
ses ; the offensive lochial discharges; and the injurious effects of 
mechanical injury, retention of coagula, or of portions of placenta, 
or of dead and putrid children. All or any of these conditions he 
considers as ready sources from which vitiated matters can be ab- 



574 PUERPERAL FEVERS. 

sorbed into the circulation. So far we think he has most ingeniously 
proved his positions. 

All the difficulties, however, in our opinion, are not yet removed. 
Dr. Ferguson takes pains to combat the opinion of Ritgen, that 
puerperal fever arises from something like a metastasis of the blood 
destined for lactification from the mammae to the peritoneum and 
uterus, by noticing that the condition exists in all women at a cer- 
tain time after delivery, whereas only a few are attacked with 
puerperal fever, (loc. cit., p. 100.) The same argument, however, 
weakens his own propositions ; for it must be acknowledged that 
numbers of cases occur, where there have been retained coagula 
or portions of placenta in a putrid state, or dead, and decomposed 
children, or injuries from the use of instruments, and yet such 
patients have recovered without any untoward symptoms. These 
are the extraordinary events ; but the existence of offensive lochial 
discharges, and of the alterations in the mucous surface of the 
uterus, are to be found in all cases of ordinary parturition. We 
can also state from our own experience, that the most serious and 
fatal forms of puerperal fever are generally those cases where the 
symptoms begin the earliest after parturition, sometimes in a few 
hours, and before pus could have been formed, or decomposition 
have taken place. It is a well-known and curious fact, that the 
severe symptoms which often follow wounds from dissection, by 
no means seem to have their intensity proportioned to the degree 
of putrefaction of the matter inoculated, but often the absorp- 
tion from the freshest bodies is the most pernicious in its effects. 
Duhamel has related an instance, in which an innkeeper and a 
butcher died from receiving accidental wounds in slaughtering an 
ox which had been over-driven ; and the blood from the same ani- 
mal produced gangrenous inflammation on the hand and cheek of 
two women who were sprinkled with it. During the progress of 
puerperal fever, in the same patient we often find, in the first in- 
stance, active inflammation with highly fibrinized blood; in its 
course, as typhoid symptoms appear, the condition of the blood is 
completely changed, while subsequently, in convalescence, its na- 
tural character becomes gradually restored. Dr. Tweedie, in his 
able article on fever, (Cyc. Prac. Med.,) has cited cases by Drs. 
Stevens and Potter, in which, during an epidemic fever, the 
blood drawn from healthy persons in the infected localities, was 
found to possess the same morbid character with that drawn from 
those actually sick, " and could not be distinguished from the blood 
of those who laboured under the most intense forms of the dis- 
ease," while blood drawn at the same season from persons living 
in the surrounding healthy districts was totally different. The paper 
of Mr. Gulliver (Trans. Roy. Soc.) has been quoted by Dr. Fer- 
guson in confirmation of his views, but with doubtful advantage. 
There is a wide distinction between the defibrinated blood in 
typhus and other malignant fevers, and the mere presence of pus 



PUERPERAL FEVERS. 575 

in the circulating fluid. Mr. Gulliver found pus in the veins in 
one case of puerperal fever only ; but he found it also in cases of 
confluent small-pox, swelled leg from ulcer, superficial wound of 
the tibia, erysipelas, suppuration of the integuments of the thigh, 
and in tubercular phthisis. In the latter class of diseases, as well 
as in lumbar or other extensive abscesses, the existence of pus in 
the veins has been long known, and has been supposed to be the 
cause of the hectic fever accompanying such diseases. But where 
it can exist with such very different symptoms, from such a diversity 
of causes, and under such a variety of circumstances, it is assuming 
too much when it is stated to be the cause of puerperal fever. In 
the experiments upon animals referred to by Dr. Ferguson, al- 
lowance ought to be made for the sudden, and what may be called 
violent, mode in which the offending matter has been introduced 
into the circulation, and so different from what takes place in spon- 
taneous absorption. It must not be forgotten that the most inno- 
cent substances, when thus injected into the veins, cause death 
rapidly, and with as much disturbance as the putrilage and fetid 
pus used in Cruveilhier's and Gaspard's experiments. In Ma- 
gendie's Lectures on the Blood, this fact is proved distinctly, and 
very much alters the force of Dr. Ferguson's arguments. Neither 
were the effects of the injection of pus, or of putrid blood, or of beef 
gravy, by any means uniform, either in degree, in the extent of in- 
jury, or in the organs injured. It is remarkable that in Gaspard's 
eighth experiment, where mercury was injected, the lesions so often 
found in puerperal fever were more especially produced in the 
sheep operated upon. 

Dr. Ferguson believes that the vitiation of the fluids is the es- 
sential cause of puerperal fever, and that the condition of the atmo- 
sphere, and the sthenic or asthenic state of the patient, only modify 
the type of the fever, as much as those circumstances are known 
to modify small-pox or measles. Time and more extended obser- 
vation will test the value of this theory ; but we are by no means 
disposed to lose sight of the influence of some preliminary effect on 
the nervous system, some previous step by which these changes 
in the condition of the blood take place. In the cold stage of 
cholera, in the onset of yellow fever, in ordinary typhus of the ma- 
lignant type, where there has been no source from which either 
purulent or putrid matters could be absorbed, we find a remark- 
able condition of the blood, its cohesive property appearing to be 
changed and even destroyed. Magendie's researches and expe- 
riments tend to prove that the most striking effects from the injec- 
tion of pus, serum, or other matters into the veins, are shown in 
the first instance by destroying the coagulability of the blood and 
altering its colour. He also states that healthy pus rarely pro- 
duces this effect, although serum, or pus mixed with serum, does so 
at once. To this want of cohesion in its particles and alteration 
in quality, Magendie attributes the lesions of the important organs 



576 PUERPERAL FEVERS. 

through which it is distributed, and the serous infiltrations that 
subsequently take place. These same conditions are produced in 
those formidable fevers and other diseases, in which one of the 
earliest and most striking changes is in the character of the 
blood, and yet without the possibility, in the first instance, of the 
absorption of pus, serum, or any other vitiated matter into the 
system. The miasmata from foul sources, whether vegetable, ani- 
mal, marshy or atmospheric, are supposed to be the exciting causes 
in these diseases, and, as shown by the symptoms, acting primarily 
on the nervous system. That the nervous system is the main in- 
strument by which this change in the blood takes place, is partly 
proved by the fact that electricity in a powerful form, and many 
of the animal and vegetable poisons which act solely on that 
system, produce the same phenomena, viz., blood divested of its 
coagulating or vital property. The effect of atmosphere, noxious 
exhalations, hospital atmosphere, and season, on the type of the 
prevailing puerperal fever, is distinctly proved ; and we think the 
fair consideration of all these circumstances leads to the conclusion, 
that the vitiated state of the blood is the secondary and not the 
primary link in the chain of phenomena, and that it occurs in 
many instances in diseases of similar character to puerperal fever, 
where it could not arise from venous absorption. Andral has 
truly and sagaciously remarked, that no line of demarkation can 
properly be drawn between the blood and the solids, and that, 
physiologically speaking, it is impossible to conceive that one of 
these two parts of the same whole could be modified without the 
other being so likewise. There is no longer any meaning, he ob- 
serves, in the disputes between the Solidists and the Hnmoralists; the 
system appears to constitute but one great whole, indivisible in the 
state of health, as well as in that of disease. The division is a dis- 
tinction of small importance, and one that is not always just, since 
it ceases to exist in the intimate structure of the organs in which all 
the grand vital phenomena take place, and in which also occur ail 
the changes that constitute the morbid state. 

On a knowledge of the predisposing causes will depend much, 
if not all, that we can do, to guard the patient from this formidable 
malady. These are, principally, mental depression and agitation, 
exposure to cold, retention of coagula and portions of the placenta, 
mechanical injuries during parturition from manual or instrumental 
aid, crowded and ill-ventilated rooms, noxious exhalations, fatiguing 
attempts to suckle, &c. The question of propagation of puerperal 
fever by contagion is a most important one, and we could enumerate 
many striking facts proving its occasionally contagious nature. It 
does not seem to us at all to militate against this conclusion, that it 
very often is not contagious, because we find the same exemption 
in other universally acknowledged contagious diseases, common 
typhus, and scarlet fever, hooping-cough, small-pox, measles, &c. 
Few who have seen much of the disease will doubt its occasionally, 



ACUTE PUERPERAL PERITONITIS. 577 

at least, being conveyed through third persons, usually the medical 
practitioner or the nurse, and therefore it is our duty to take all rea- 
sonable precautions in visiting healthy parturient women upon 
leaving those who are labouring under the disease. 



A. ACUTE PUERPERAL PERITONITIS. 
I. SYMPTOMS. 

The simplest form of puerperal fever is that of peritonitis. On 
the second, third, or fourth day after delivery, in some instances 
much later, the patient is seized with a severe rigour, accompanied 
or speedily followed by acute pain in the abdomen, generally in the 
hypogastric region. The pain is constant, though there are often 
exacerbations at irregular intervals ; it is increased by pressure ; and 
the tenderness, which is speedily followed by fullness and tension, 
rapidly extends over the whole of the abdomen, often to the pit of 
the stomach. The patient lies on her back, the pain being aggra- 
vated by turning to the side : the extremities are generally slightly 
drawn up, to relax the abdominal muscles, and to avoid the pressure 
of the bed-clothes. The local symptoms are always accompanied 
with well-marked constitutional disturbance ; the secretions, more 
especially the milk and lochial discharges, are checked ; the skin 
becomes hot, the pulse rapid, small, and wiry, or sometimes full and 
bounding. The tongue is sometimes creamy and moist, often dry 
in the centre, with a dirty coat ; now and then it is scarcely affected. 
There are sometimes, but not constantly, great pain of the head with 
throbbing of the temples, want of sleep and restlessness, with occa- 
sional vomiting. The countenance is anxious, often suffused. The 
respiration is hurried, whilst the slight disturbance or bodily exer- 
tion increases the abdominal pain. If the proper remedies be 
promptly employed, and the disease yield to them, the pain gradu- 
ally abates, the tenderness not so soon, the skin becomes moist, the 
pulse subsides, the milk and lochial discharge become more abun- 
dant, and the patient begins to change her posture from the back to 
the side. All these are promising signs of recovery, and unless 
there should be a relapse, by no means an uncommon event, she is 
well again in two or three clays. In other instances, however, the 
result is different. The pain and tension of the abdomen increase, 
and often sudden or nearly sudden subsidence of the pain after some 
hours takes place ; the abdomen feels hard and tympanitic; the pulse 
becomes more and more rapid, as well as feeble and thready; the 
skin clammy and cold ; there is occasional confusion of ideas, which 
is soon followed by low muttering delirium ; the tongue becomes 
dry and brown, the teeth covered with sordes; the patient is dis- 
tressed with eructation or with vomiting, sometimes of dark or 
green matter: hiccough, twitching of the limbs, sunk and cadave- 
37 



578 ACUTE PUERPERAL PERITONITIS. 

rous countenance, and cold extremities, are the sure indications of 
approaching death. Though this is the common course of the disease 
when fatal, the symptoms do not always assume this exact form, 
but what is termed a latent character. There is often no confusion 
of intellect to the last ; the situation of the pain varies, or it may be 
entirely absent. Some years ago we assisted at the examination of 
a patient in the British Lying-in Hospital, who had constant sick- 
ness but no abdominal pain, except at the pit of the stomach, and 
no tenderness on pressure; and yet the appearances proved that 
extensive and violent peritoneal inflammation had existed. 

This form of puerperal fever is often epidemic ; it is that which 
has been described by Dr. Gordon, Dr. Armstrong, Mr. Hey, and 
others ; and although much more fatal when epidemic than when 
in a sporadic form, is, when taken in time, most under the control 
of remedies. It now and then creeps on more insidiously, is not 
preceded by any distinct rigor, the pains of the abdomen are more 
intermitting and are mistaken for after-pains, but the pulse always 
becomes suspiciously rapid, and whenever this is the case,immediate 
alarm should be taken. 



II. ANATOMICAL CHARACTERS. 

On dissection of cases of acute puerperal peritonitis, the following 
appearances are found : — The peritoneum preternaturally and uni- 
formly red and often thickened ; sometimes it is here and there pale ; 
with effusion of serum into the abdominal cavity mixed with flakes 
of coagulable lymph. The intestines are distended with flatus, and 
matted together by patches of coagulable lymph. These appear- 
ances are more or less diffused over the fundus of the uterus, on the 
reflexions of the peritoneum, upon the uterine appendages, on the 
omentum, the liver, and other viscera, and not unfrequently over 
the peritoneal covering of the diaphragm. The ovaries, the uterus, 
and the Fallopian tubes are often coated with a creamy fluid, and 
sometimes purulent deposits are found in the muscular structure of 
the uterus and in the ovaries, the natural structure of the latter being 
often completely disorganized and converted into sacs of purulent 
matter. 



III. TREATMENT. 

The treatment, to be successful, must be early and prompt ; 
every hour of delay; after the onset of the symptoms is of the 
utmost importance. The medical attendant is rarely summoned 
until the rigor has ceased, and the pyrexia is established. If the 
patient is seen sufficiently early during the rigor, hot diluents and 
perhaps an emetic should be given ; and hot fomentations or poultices 



TREATMENT. 579 

should be freely applied over the abdomen. A full dose of calo- 
mel with James's powder and opium may be administered, and 
in a couple of hours a purgative of castor oil, salts and senna, or 
jalap. Warm water injections may be thrown up the rectum, and 
also the vagina. — We have often found these remedies, when used 
at once, sufficient to arrest the disease. In 1822, when the writer 
was house-surgeon at the Lying-in Hospital, where an epidemic 
puerperal peritonitis was very prevalent both among the in and out 
patients, several cases were arrested, apparently in limine, by this 
treatment. If, however, we find the pulse increasing, and the 
symptoms not alleviated; or if, as is most likely, we do not see the 
patient till after the rigor has subsided, and the disease is estab- 
lished, it will be necessary to bleed. Should the patient be feeble 
and delicate, and the symptoms not severe, or the pulse much 
accelerated, we may perhaps be satisfied with the application of 
leeches to the abdomen ; but they are in general much better kept 
in reserve for future purposes : we must regulate the mode of ab- 
stracting blood, as well as the quantity, by the strength of the 
patient and the effect produced. The object being in nearly all 
cases to produce the greatest possible effect with the least loss of 
power, the best plan is to bleed in the erect posture and from a 
large orifice. The quantity taken must of course depend upon 
circumstances : we have been most satisfied when decided faint- 
ness has been produced; if, however, upon recovery from deli- 
quium,the pulse be still hard and quick, and the pain not decidedly 
relieved, it will be prudent to continue the flow of blood till those 
objects have been attained. The patient should be visited within 
six hours, and if there be recurrence of the pain, and if the pulse 
again become hard and quick, more blood must be taken. This 
second bleeding may perhaps be followed by a third, according to 
circumstances ; but symptoms of debility are apt so soon to show 
themselves, that subsequent bleedings are often better when only 
local, by means of leeches, the number being applied proportionate 
to the degree of pain and tenderness. The pulse is the best guide, 
for the pain, after the first full relief from the bleeding, is often of a 
mixed character, partly inflammatory and partly nervous — to be 
detected only by watching closely the other symptoms. The ten- 
derness is a less certain guide, for few will bear pressure for a 
considerable time after the inflammatory symptoms have been 
entirely relieved. Many patients also from fear shrink from the 
pressure of the hand, although, by drawing off the attention, it 
will be found that they bear firm and steady pressure very well. 
As a most valuable adjunct to the abstraction of blood, mercury 
must be freely given. In the cases now under consideration, after 
having tried almost every form and every dose, we give the pre- 
ference to calomel, in moderate doses at short intervals. After the 
bowels have been freely emptied, we generally order five grains 
of calomel every two, three, or four hours, according to circum- 



580 ACUTE PUERPERAL PERITONITIS. 

stances : it is decidedly more efficacious when combined with 
Dover's powder, or with James's powder and opium. Many- 
object to opium in these cases — that it masks the disease ; but 
when thus combined, we deem it to have a material influence in 
allaying the symptoms, and preventing the confusion often arising 
from the mixed nervous inflammatory or even spasmodic pain, 
which for the first two or three days after labour is so apt to exist. 
Hot poultices or fomentations to the abdomen are to be frequently 
applied — a hot light linseed meal poultice is on the whole most 
convenient and most easily borne, and should be changed as often 
as it gets cool. In the majority of cases, if no marked relief has 
been obtained before, the symptoms yield when the mercury begins 
to affect the mouth, the signs of recovery mentioned before taking 
place. In less favourable cases, when, in spite of remedies, the 
disease advances, much good may be gained by the application of 
hot turpentine to the surface of the abdomen, or a large blister 
may be applied, and the sore dressed with mercurial ointment. 
We have witnessed in some cases the most striking advantage 
from this remedy, even when every sign of effusion had taken 
place. When there is great distension of the abdomen, with eruc- 
tations, sickness, and the pulse varying from 130 to 160, remission 
of the pain, and a clammy cold skin, even then we need not despair. 
Nourishment and stimulants, wine, brandy, and ammonia, should 
be freely administered. In such cases the internal exhibition of 
the turpentine has now and then succeeded, though no practitioner 
who has made trial of this remedy has found it so successful as Dr. 
Brenan, of Dublin, has stated it to have been in his own practice. 
But as a forlorn hope, after effusion had taken place, we have 
known it often tried, and in two cases with success. In some 
others the effect of the first dose was so decisive in carrying off 
flatulence, and allaying the tympanitic swelling, that we have been 
much disappointed to find the rapid return of all the mischief. Dr. 
Joseph Clarke found it equally tantalizing, and very difficult to 
get the patients to continue the doses after the first had produced 
relief. (See his letter in Appendix, No. II., cited by Armstrong.) 
In the progress of the alarming symptoms of collapse, the only 
hope is in the constant watchfulness of the attendant; and as we 
have known a few cases recover when everything seemed despe- 
rate, we feel inclined to urge the most devoted application of all 
the usual restoratives to the last. Some years ago we left a patient 
at the Lying-in Hospital so far gone, that it was predicted she could 
not live through the night ; she was alive and improved the next 
morning ; the house-surgeon had never left her, had supplied her 
with brandy and egg at short intervals by teaspoonfuls, and in a 
fortnight she left the hospital quite convalescent. Such is the 
treatment we should recommend in this form of puerperal fever. 
The minute details must depend on the circumstances of each case. 
It is impossible to do more for the young practitioner than to give 



ADYNAMIC OR MALIGNANT PUERPERAL FEVER. 581 

him the outline, and it is only by his personal experience that he 
can gain the art of weighing the comparative importance of symp 
toms, and the most ready means of meeting them. 



B. THE ADYNAMIC, OR MALIGNANT PUERPERAL FEVER. 
I. SYMPTOMS. 

There is another form of puerperal fever, however, of a much 
more dangerous and fatal description. The symptoms differ in some 
respects from the acute peritoneal inflammation just described, and 
in many of the cases the morbid appearances found upon dissection 
are essentially different. It would be satisfactory if we could always 
trace the connection between the peculiarity of the symptoms and 
the morbid changes, as it would simplify our knowledge of the sub- 
ject, and in time improve the treatment. Dr. Robert Lee has 
attempted this, but we are obliged to confess that our experience by 
no means confirms the accuracy of his descriptions. In the low or 
malignant forms of puerperal fever, we have certainly met with 
the appearances on dissection which he has well described, but we 
have often met with the same character of symptoms equally fatal 
in their course, but have not been able to discover the morbid ap- 
pearances in the structure of the uterus or its appendages mentioned 
by him and by some French and German writers. In the epidemics 
which prevailed in the Dublin Lying-in Hospital, during the time 
that Dr. Collins was master (from 1826 to 1829), which were very 
fatal, though many of the cases were of this malignant character, 
and typhus fever with petechial eruptions was prevalent at the same 
time in the city, in by far the majority of the cases the deeper seated 
structures were but little affected. The symptoms of this form of 
the disease are, to a certain extent, similar to those of acute puer- 
peral peritonitis ; there is often a rigor, but by no means always 
well marked ; the pain in the abdomen is less severe, and in some 
cases more circumscribed, and often limited to the hypogastrium or 
to the right or left iliac regions, often both sides being affected. 
There is less tenderness on pressure, and the pain in some instances 
appears deeper seated. In these cases it would be very satisfactory 
if we could trace a connection between the symptoms and the mor- 
bid appearances ; for instance, where the seat of pain and tender- 
ness is in the right or left groin, that the ovaries, broad ligaments, 
and Fallopian tubes are, in the first instance at least, the seat of 
inflammatory action; and where the hypogastrium is principally 
attacked with deep-seated pain and tenderness, that the uterine 
structure is affected. The appearances found in two fatal cases 
which occurred in the General Lying-in Hospital, in the early part 
of 1838, will prove the fallacy of" this conclusion. In the first, the 
symptoms came on the third day after delivery, and the patient 



582 ADYNAMIC OR MALIGNANT PUERPERAL FEVER. 

survived three days only. On dissection the following were the 
appearances— general peritoneal inflammation; disorganization of 
both ovaries, particularly the left; and a collection of purulent 
matter in the folds of the broad ligament near its connection with 
the uterus. In this case the patient had no pain in any part of the 
abdomen, even on deep pressure. In another case trie symptoms 
were well marked on the second day after delivery, and proved 
fatal within twenty-four hours. The morbid appearances noted 
after death were, slight effusion, not more than an ounce and a half 
of fluid in the abdominal cavity, complete disorganization of the 
ovaries, with sloughing of the lining membrane of the uterus. In 
this case there were pain and tenderness of the abdomen, principally 
referred to the umbilical region. Such contradictory symptoms are 
so common, that they cannot be fairly classed under the head of 
anomalies, and seem to justify the conclusion that, in the present 
state of our knowledge, we are not entitled to consider the changes 
of structure found after death as conclusively indicated by the pre- 
vious character and situation of the pain. 

The most formidable symptoms of this form of puerperal fever 
are to be found in the pulse, the countenance, and the nervous sys- 
tem. In all of these cases the pulse is, at a very early period, 
extremely small, rapid, and compressible, varying from 130 to 160; 
the countenance is remarkably anxious and sunk, with a livid, often 
a yellow tinge of the skin ; there are much more restlessness and 
tossing than in the more active inflammatory fever, nor does altera- 
tion of the posture appear to increase the pain as much as might be 
expected. The muscular powers, however, are extremely prostrate ; 
there is great mental depression, and though the intellect often re- 
mains clear to the last, in the majority of the cases there is low 
muttering delirium ; the tongue is coated, at first with a white, and 
soon with a dirty yellow fur, which soon becomes dry and brown, 
though often in hospitals, during epidemics, the disease runs its 
course so rapidly, that there is no time for this last change in the 
appearance of the tongue. Dr. Gooch's remark as to the effects of 
remedies, becomes here a valuable guide. Where blood is taken 
from the arm, a very small quantity produces faintness, and the 
blood is usually dark, the coagulum formed is loose and easily 
broken down, and the serum is separated slowly and imperfectly. 
After even a very small bleeding, the patient's prostration of 
strength is frightful, and the urgency of the symptoms is increased. 
Diarrhoea is a very common attendant, the evacuations being often 
highly offensive, and the patient is often distressed with eructation 
and vomiting. The lochial discharges are fetid, but by no means 
always suppressed. The abdomen is very early tympanitic, but 
firm steady pressure more frequently relieves than aggravates the 
pain. The breasts speedily become flaccid from subsidence of the 
milk : there is an eagerness for cold drinks, or, on the other hand, 
for brandy or porter; but now and then an indifference to all sus- 



ANATOMICAL CHARACTERS. NATURE. 583 

tenance, and a dislike to be disturbed. The stage of collapse soon 
succeeds, and the symptoms often run their course, during hospital 
epidemics, with such astounding rapidity, that death may take place 
in a very few hours. We have long remarked, that whenever the 
disease begins very shortly after delivery, within the first twelve or 
eighteen hours for instance, the more intense and rapid is its progress 
and the result more constantly fatal. 



II. ANATOMICAL CHARACTERS. 

The anatomical characters vary in this as they do in the more 
active forms of puerperal fevers. Most commonly, in our experience, 
in the peritoneum, throughout its whole extent, the principal mor- 
bid appearances are to be found. There is a large quantity of fetid 
gas in the intestines and abdominal cavity. The peritoneum has a 
dusky hue, very unlike the bright florid appearance of the acute pe- 
ritonitis. The effused fluid has a dirty, brown, often bloody appear- 
ance, and is peculiarly glutinous (mentioned also by Dr. Collins). 
The shreds of lymph, when there are any, are loose and destitute 
of firmness. In many, perhaps in the majority of these cases, the 
morbid changes are thus limited, and by the most careful search, 
none of the other textures exhibit any morbid alteration. But as 
in the more active inflammatory disease, lesions of other organs 
are often discovered, more especially the uterus and ovaries, the 
structure of which is broken down and pulpy, that of the uterus 
often approaching to gangrene. In 1829, in the Maternite at Paris, 
of 222 fatal cases, forty-nine exhibited this ramollissement of the 
uterus. In many of the worst cases in the General Lying-in Hos- 
pital, a sphacelated condition of the lining membrane of the uterus 
was found; and in Waldron, in the year 1836, the whole structure 
of the uterus was, to use the words of the house-surgeon, who re- 
corded the case, "fairly rotten" In this instance, and in some 
others, there was a peculiar fetor from the whole of the abdomen 
for two days or more before death. It is to be regretted that in by 
far the majority of the fatal cases in our lying-in hospital, the friends 
prevented post-mortem examinations. 



III. NATURE. 

It would seem then, from the history of many of the cases, that 
although the same structures are attacked in both these forms of 
puerperal fever, and also, although the nature of the affection is 
evidently inflammatory in both, the character or type of the inflam- 
mation is manifestly different. In what this difference consists 
appears to be the chief difficulty ; and we are inclined to attribute 
the diversity in the character of puerperal epidemics to this differ- 



584 ADYNAMIC OR MALIGNANT PUERPERAL FEVER. 

ence, rather than to variety in the locality of the inflammation itself. 
We see very different forms of inflammatory action under other cir- 
cumstances, and why not in this? We admit, the scrofulous, the 
rheumatic, and the erysipelatous forms of inflammation to be as 
distinct as the dynamic and adynamic, and why may we not allow 
a difference in the nature of the local inflammation in puerperal 
fevers ? The distinction appears to us to depend mainly on the 
energy, or want of energy, in the nervous system. In epidemics, 
this difference is generally remarkably shown, and the great fatality 
of puerperal fevers in London lying-in hospitals is evidently much 
influenced by the previous moral and physical condition of the 
patients. A great number are half-starved before admission. In 
reading over the recorded cases of our lying-in hospital, one of the 
patients on her admission is said to have devoured her food in the 
most ravenous manner, having evidently been deprived of whole- 
some food for days before. A considerable number of the women 
are habitual dram-drinkers, and on losing their daily stimulus, 
rapidly fall into a state in which disease is excited from the most 
trifling causes, and becomes strikingly fatal. The late respected 
and intelligent matron was so convinced of this being frequently a 
cause of puerperal disease, that she administered with the best 
effects gin mixed with gruel to the poverty-stricken unfortunates, 
when they began to show, a day or two after delivery, a peculiar 
prostrated look and manner with a trembling tongue, which her 
experience easily detected. In the spring of 1838, when puerperal 
fever was remarkably prevalent and more fatal than was ever before 
known in the lying-in hospital, it was discovered that there was an 
open sewer, 200 yards in length, immediately at the side of the 
building, which had become exceedingly foul and offensive. The 
hospital was closed for several weeks, but the first cases readmitted 
were attacked with fever, and there was no remedy but again to 
close the hospital and take measures to cleanse and inclose the 
sewer.* The suddenness and the fatality of the fever were pre- 
cisely like that form of typhus fever which often arises from expo- 
sure to similar miasmata, the effect of which on the nervous system 
is well known. t 

* The hospital was re-opened in the first week of November. From that time 
to the 1st of August, 1839, 142 cases were admitted : 7 or 8 cases of decided puer- 
peral fever have occurred, and a few of abdominal pain and tenderness: all the 
cases recovered. 

f In an early volume of the Medical Gazette, are recorded some striking cases of 
this description which occurred at Clapham, and were clearly traced to exposure 
to the putrid exhalations from the contents of a privy which had been emptied and 
discharged near the house. 



TREATMENT. 585 



IV. TREATMENT. 

The treatment of this form of malignant puerperal fever has been 
very unsatisfactory. Dr. Gordon, Mr. Hey, and Dr. Armstrong, the 
advocates for large bleedings in all cases, because they happened to 
see epidemics which would bear it and demanded it, have said that 
the fatality of the low puerperal fever of London must have arisen 
from timidity, and not pushing bleeding to a sufficient extent; that 
however feeble and rapid the pulse, bleeding was the only remedy 
to be depended upon, and that the pulse would rise on the loss of 
blood. An oppressed pulse would certainly do so in many instances, 
but there is a certain and important difference between the op- 
pressed and really feeble pulse, though many can with difficulty 
distinguish the one from the other. The earliest experience of the 
writer in puerperal fever was in two distinct and well-marked epide- 
mics in the spring of 1822. From the decided advantage of copious 
bleeding in the first, we were naturally led to push what is com- 
monly called bold practice in the first cases of the second, but the 
result soon proved our rash mistake. These adynamic cases will 
not bear bleeding favourably — a very few ounces will soon produce 
fainting followed by rapid collapse. It should, however, be kept in 
mind, that in an epidemic of this description, cases of an opposite 
character occasionally occur. Women of robust constitutions, pre- 
vious to the attack in comfortable circumstances, and accustomed 
to a generous diet, may have the active form of the disease, while 
dozens of patients are suffering under the other form in the same 
wards. We must be guided, then, by the condition of the patient, 
as well as by the character of the prevailing epidemic. Unless 
the pulse be exceedingly powerless, we may try the effect of 
blood-letting ; should the patient quickly turn faint, the best way is 
to close the orifice and wait patiently till the blood has had time to 
show its condition. If marks of active inflammation are apparent, 
the vein may be again unclosed, and more blood taken ; and gene- 
rally after the first faintness has subsided, a much larger quantity 
will flow than might have been expected. The pulse must be 
closely watched, and the arm bound up, when its feebleness shows 
that sufficient blood has been drawn to affect the circulation. If 
we are unable to take blood from the arm, we may apply leeches 
to the seat of the pain, from one to four or five dozen, according to 
the degree and extent of the pain, as well as the strength of the 
patient ; for some it must be borne in mind, are even struck down 
by a few leeches. Where the pain is chiefly referred to the uterus, 
and particularly if that organ is felt swollen, hard, and tender ; a 
few leeches applied to the os uteri and cervix, by means of a 
uterine leech-tube, will give greater relief, and with less loss of 
power than four times that number externally. Leeches thus ap- 
plied are likely also to be most serviceable where the lochia! dis* 



586 ADYNAMIC OR MALIGNANT PUERPERAL FEVER. 

charge is stopped. Cataplasms to the abdomen, as long as there is 
no tension, are sufficient ; they give relief, and also promote a warm 
perspiration. But if there are early tympanitis and much eructation, 
the application of a blister, or of hot turpentine, will be found 
more serviceable in relieving the pain and allaying the flatulence. 
Though often much disappointed in the effect of mercury in this 
form of puerperal fever, we do not know any remedy from which 
manifest good has been so frequently derived. Dr. Collins has 
remarked a great difficulty in affecting the mouth with mercury in 
these cases, which agrees with our experience. We have seen 
many cases recover where the mouth has not been affected, and 
several die where full mercurialization had been established. But 
on the whole, when the constitution is shown to be under the mer- 
curial action, the symptoms usually improve, the healthy action is 
slowly restored, and the pulse becomes steadier and quieter. Along 
with calomel, in doses of three to five grains every hour or two, 
we are in the habit of giving Dover's powder, or a combination of 
James's powder and opium, from half a grain to a grain of the 
latter. The larger doses of calomel have not been so successful in 
our practice as they appear to have been in that of others. We 
have given twenty-grain doses every four hours, but though in 
some it produced rapid salivation, and with advantage, in most of 
the cases it produced much distress, and failed to arrest the disease. 
Dr. Collins gave often upwards of 300 grains of calomel in thecourse 
of the treatment of a single case, and to another which recovered he 
administered 308 grains in twenty-four hours, and one patient took 
an ounce. He preferred three or four grains of ipecacuanha in 
combination with the calomel, which rarely produced nausea after 
the first dose. To many of the patients he also gave opium freely, 
in combination with calomel. He also occasionally gave it uncom- 
bined ; but opium alone is chiefly beneficial in another form of 
puerperal fever, which will be hereafter described. Where with 
the other symptoms there is distressing diarrhoea, we generally find 
the hydrargyria cum creta combined with opium and ipecacuanha, 
more useful than calomel. It may be given in ten-grain doses, 
with from three to five of the Dover's powder. 

Although in the acute form of puerperal fever the patient is to 
be kept upon the thinnest farinaceous food, in this form nourish- 
ment and even stimulants are early required. It may at first sight 
appear contradictory to prescribe leeches and mercury at the same 
moment with strong broths, jellies, and even wine and cordials ; but 
experience proves the value of the practice. In the low condition 
of the nervous system, energy is wanted to produce healthy action, 
and without supporting the vital powers we find the patient sink 
much more readily under the influence of disease. This is a very 
important point in the treatment, and should always be kept in 
view. In the hospital we find the gin caudle, when prudently ad- 
ministered^ very valuable assistant in the treatment of the disease, 



TREATMENT. 587 

although as far as symptoms can prove it, inflammatory action 
exists, bat then it is adynamic inflammation. Some of the distress- 
ing symptoms must be relieved by other remedies. Effervescing 
saline draughts, containing the bicarbonate of ammonia in camphor 
or mint julep, allay the sickness and eructations. Turpentine in- 
jections occasionally subdue the tension of the abdomen, but are 
inadmissible when there is troublesome diarrhoea. Injections of 
weak solutions of the chlorate of soda or lime, in warm gruel, into 
the vagina are useful, by correcting the fetid vaginal discharges 
should they exist. Dr. Collins has great confidence in the use of 
the warm bath ; and though we have had no personal experience 
of it, we should be inclined to recommend it from his report. We 
have hitherto been deterred from the trial from the pain experienced. 
on the least movement, and from the sensation of great exhaustion 
complained of; though when carefully managed, with ample and 
skillful assistance, this objection may be obviated ; and it would be 
very likely to soothe the restlessness and promote free perspiration 
with an equal circulation. 

There are often cases of a more protracted nature, which attain 
a certain approach to convalescence, but linger on for many days, 
and eventually sink. There are others where the whole disease 
appears to be chronic or subacute, and such cases are often met 
with, where there are no other suspicious symptoms than a look of 
anxiety, great sense of exhaustion, and a rapid pulse. We remem- 
ber a patient who, on the eighth day of these symptoms, having had 
an accidental injury, exclaimed it was quite a relief to feel pain. 
These cases are insidiously dangerous, and it is a safe rule always 
to be on the watch when the pulse keeps up above 100 for any 
number of days after parturition. In the majority of these cases, 
tympanitis or effusion into the peritoneal cavity comes on at last, 
and they run the usual course, although no very prominent symp- 
toms. have been previously noticed. In these, however, we find the 
same variety in the appearances on dissection that have been already 
noticed ; in many the peritoneum alone shows signs of mischief; in 
others the uterus is principally affected; and again there are ab- 
scesses in the ovaries, the broad ligaments, and the Fallopian tubes. 
It is in the protracted cases, following more acute symptoms, that 
we have most frequently found the purulent deposits in the sub- 
stance of the uterus, with or without the same occurrence in the 
joints or other parts of the body. In some of these instances there 
is no pain in the joints, or in the parts where the collection of pus 
takes place; but in many (as happened in the epidemic of 1822), 
there are phlegmonous appearances attended with acute pain. In 
those cases the calf of the leg and the elbow joint were uniformly 
affected, painful inflammation with hard tumefaction came on, and 
in a day or two an abscess formed. Many of these patients re- 
covered, but the convalescence was exceedingly slow, and several 
times fresh abscesses formed at a time when all appeared satisfac- 



588 ADYNAMIC OR MALIGNANT PUERPERAL FEVER. 

tory. The remarkable destructive inflammation of the eye, which 
has been already mentioned, rare as it is, can hardly, perhaps, be 
placed as a symptom peculiar to this form of puerperal fever ; but 
we have witnessed four instances of it, and in each there were puru- 
lent deposits in various parts of the body. In the five cases related 
by Dr. Marshall Hall, which also occurred after delivery, the 
same fact was noticed ; there was the same rapid pulse with con- 
stitutional disturbance, lasting for many days before the inflamma- 
tion of the eye was discovered. In Dr. Hall's cases the left eye 
was uniformly the one inflamed, and it is curious that such was the 
fact in the four which have come under our own knowledge. In 
only one of Dr. Hall's cases were any decided abdominal pain and 
tenderness noticed, whereas three out of the four of our cases had 
such symptoms. In none could any post-mortem inspection be 
obtained. Dr. Robert Lee (Cyc. Prac. Med., ait. Puerperal 
Fever) has alluded to two cases under his own care, where this 
destructive inflammation of the eye occurred in both eyes. He is 
inclined to believe, that this remarkable affection is the attendant 
upon the " morbid condition of the veins of the uterus," the puru- 
lent or other depraved secretions entering the system, and acting as 
a poison on the whole mass of blood. In Dr. Hall's cases and 
our own, no examination took place to elucidate this theory, and 
Dr. Lee does not quote any dissections to confirm it. 

It may appear presumptuous to recommend any course of treat- 
ment in a disease which, as far as we know, has always been fatal ; 
but in one case which we witnessed, so much marked benefit was 
obtained by stimulants, a generous diet, bark, ammonia, and large 
doses of opium, though the patient relapsed by an accidental altera- 
tion of the plan, that in a similar case we should certainly be in- 
clined to follow it: such a course has also been the most successful 
in the instances of purulent deposits, without the affection of the 
eye. 

In the chronic forms of the puerperal affection we have noticed, 
without these additional symptoms, a large blister over the abdo- 
men, dressed with mercurial ointment, has been occasionally bene- 
ficial. iVmong the varieties of plans that have been tried, the 
topical application of ice to the abdomen may be mentioned ; and 
with this some have recommended the internal administration of 
ice and iced drinks. We witnessed, many years ago, some sporadic 
cases treated in the former manner, and they recovered ; but the 
symptoms were by no means severe, and within the last year it 
was adopted in some of the cases in the Lying-in Hospital, but not 
with any satisfactory results. The iced drink was very grateful, and 
taken with avidity ; and though we could not trace any bad effects 
decidedly to the remedy, yet certainly no permanent advantage 
resulted. When in the epidemic already alluded to, the symptoms 
were accompanied with petechial blotches, a fatal adynamic, " spot- 
ted fever" was prevalent in many parts of the metropolis. In some 



PUERPERAL INTESTINAL IRRITATION. 589 

of the hospitals such cases were treated with marked benefit on the 
saline plan, recommended by Dr. Stevens in the West Indian 
fever and in cholera. On this account the saline medicines were 
given to many of our puerperal fever patients, whether petechia 
were present or not ; but the result was by no means encouraging. 
The congestive form of puerperal fever (so termed by Dr. Arm- 
strong), is in our opinion merely a highly aggravated form of the 
first stage of the ordinary disease.* When reaction is established, 
if that can be brought about, the same train of symptoms follows, 
and the same course is run. A patient may die before reaction 
takes place, as they may die in the cold fit of an ague, or of some 
of the virulent tropical fevers ; but we do not believe there is any 
peculiarity in the type of the disease, except in the intensity of this 
first stage. Hot baths, diffusible stimulants, hot frictions, stimulat- 
ing injections, and perhaps emetics, form our chief resources to 
bring on reaction ; and in some cases very cautious abstraction of 
blood may be employed, to relieve the right side of the heart, and 
promote a more free circulation. If the blood flows after the first 
few moments with freedom, and the pulse becomes more distinct, 
and the aspect of the patient improves, we may with confidence 
allow more blood to flow, but not enough to produce faintness. 
Where death has taken place in this congestive stage, as might be 
expected, the venous system is found gorged, and there are no 
traces of inflammatory action or effusion. 



C. PUERPERAL INTESTINAL IRRITATION. 

A far more common variety of puerperal fever, if it can be so 
called, and one of great consequence to discriminate, is that arising 
from intestinal irritation. It is not in itself inflammatory, and it 
does not necessarily lead to inflammatory action of any sort, but it 
is very apt to be mistaken, and to terminate fatally, and in a great 
measure from the bad adaptation of treatment. Besides this, it is a 
very frequent cause of the other varieties of puerperal fever, and 
intestinal irritation often accompanies, and seriously complicates, 
the more simple forms of those diseases. At any period after 
delivery, where the bowels have been previously neglected or mis- 
managed, this affection may come on. 



I. SYMPTOMS. 

The symptoms are more gradual in their progress at first : there 
is general uneasiness, scarcely describable by the patient, often for 
some days before the more marked symptoms make their appear- 

* "I have seen a few who never grew warm after the rigor, which then resem- 
bled a convulsion." (Denman's Midwifery, 6th ed., p. 434.) 



590 PUERPERAL INTESTINAL IRRITATION. 

ance ; the appetite fails; the tongue becomes coated with either a 
creamy, or a dirty white ; the skin is over-cool for part of the twenty- 
four hours, and that state alternates with irregular febrile heat, ac- 
companied often with headache, and generally a quick pulse ; there 
is frequently deep-seated uneasiness in the abdomen, which is full 
and rather tense, often rather tender to pressure, but not generally 
to firm steady pressure ; there is a frequent feeling of sickness, and 
often vomiting : sometimes this vomiting is profuse and incessant, 
and the fluid ejected is dark and offensive*: in many instances this 
is thrown off the stomach with little or no effort, but apparently 
from the effect of flatulence. A very common symptom, more 
especially after the first day or two, is diarrhoea ; the evacuations are 
dark, fetid, watery or slimy, with much flatulence, fetor of the 
breath, and increased abdominal tenderness ; the pulse increases in 
rapidity; the exacerbations of fever are of longer duration, and 
attended with great prostration of strength and feeling of despond- 
ency ; the tongue indicates subacute gastric inflammation — it is 
sometimes white in the centre with florid edges and tip, the bright 
red, angry-looking portion suddenly emerging from the border of 
the white coat ; at other times the white or yellow coat entirely 
disappears, and the whole tongue is left morbidly red, shining, and 
glossy ; in some cases perfectly glazed ; in others it is rough, and as 
it were scalded, the mucous membrane of the mouth being at the 
same time often covered with aphthae. The strength of the patient 
rapidly diminishes under the exhausting diarrhoea and the continual 
or irregular fever, and death is generally preceded by some of the 
symptoms of the other forms of puerperal fever. Many of these 
cases are treated by bleeding, on the supposition that they are 
inflammatory, but bleeding only aggravates the symptoms. They 
are also more likely to arise after labours which have been unusually 
protracted, or where uterine hemorrhage has occurred to a great 
extent. In the latter instances, besides the symptoms described, 
there is much affection of the head ; acute pain, with strong pulsa- 
tion in the centre, confused noises, want of sleep, low delirium, and 
constant restlessness. In spite of the palpable cause of these dis- 
tressing sensations, it is by no means uncommon to find this form 
of child-bed fever mistaken for vascular plethora, and the tempo- 
rary relief to the head, obtained by the local abstraction of blood, 
has often led to a repetition of exhausting remedies. 



II. ANATOMICAL CHARACTERS. 

In several instances which have fallen under our notice, where 
death took place, the most striking circumstance on post-mortem 
examination, was the entire absence of organic changes. There 
was generally a large quantity of air in the instestines and stomach, 
a pale and bloodless state of all the tissues and organs, venous con- 



DIAGNOSIS. TREATMENT. 591 

gestion in the vessels of the brain, but no lesion sufficient to account 
for death. In some of the more protracted forms accompanied with 
diarrhoea, the mucous membrane of the large intestines is now and 
then found ulcerated in patches ; and in other portions of the canal 
it has assumed a peculiarly smooth appearance in the interspaces 
of the mucous follicles. Where the condition of intestinal irritation 
has been accompanied or followed by other symptoms denoting 
more serious disorder, the appearances on dissection are found simi- 
lar to those which have been previously described. 



III. DIAGNOSIS. 

It is most important to detect this form of mischief early, and to 
distinguish it from the more formidable conditions of the puerperal 
state. They are, however, so often blended or complicated, as to 
increase materially the difficulty. When uncomplicated, the chief 
points to be noticed are, the insidious character and slow progress 
of the symptoms, the state of the tongue, and the condition of the 
secretions. The absence of acute pain and tenderness is not to be 
much depended upon, as it has been already observed that those 
symptoms are not always present in the peritoneal fevers. The 
irritable state of the tongue, the peculiarly foul and offensive evacu- 
ations, and the subsequent diarrhoea, when existing along with the 
signs of inflammatory mischief in the abdominal or pelvic cavity, 
whether of the sthenic or malignant character, are all to be taken 
as evidences of the complication of this state of intestinal irritation 
with the genuine puerperal fever. 



IV. TREATMENT. 

In describing the treatment, we shall limit our observations to 
the simple state of intestinal irritation; the modification of such 
treatment, when applied to the complicated varieties, must depend 
entirely on the nature and peculiarities of the accompanying disease. 
The obvious indications are, to remove the offensive matter from 
the bowels, to alter and improve the depraved secretions, and to 
sustain power without increasing febrile action. When we are 
called to such a case early, a full dose of calomel, James's powder, 
and opium, may be given, followed in four or five hours by castor 
oil, which is generally the most efficient and the least irritating pur- 
gative. If there be much sickness, so that such remedies will not 
be retained, from five to ten grains of calomel alone will almost 
always allay the vomiting ; after which, a large enema of gruel and 
castor oil may be injected. Several successive doses of purgatives 
will generally be required to remove the scybala and offensive accu- 
mulations from the intestines, and a change of purgative will fre- 



592 PUERPERAL INTESTINAL IRRITATION. 

quently accomplish this, when the first has latterly brought away 
nothing but watery motions. The repetition of the purgatives must 
depend on the strength of the patient and on the effect produced, 
the full state of the abdomen, when felt by the hand, being our 
guide as to the existence still of an unremoved load. When diar- 
rhoea is an early symptom, or at least has begun before we see the 
patient, we shall do but little good in our efforts to restrain it, unless 
we give these active purgatives. Chalk mixtures and astringents 
only aggravate the symptoms in the first instance, the cause which 
keeps up irritation still remaining. After we have succeeded in 
cleansing the bowels, milder alteratives will be sufficient. The 
hydrargyrum cum creta, or small doses of calomel combined with 
ipecacuanha and prepared chalk, may be given at short intervals, 
interposing some mild laxative, as rhubarb and magnesia, or castor 
oil, once in one or two days. Where the patient has been much 
exhausted, an enema of gruel may be given ; and if there is much 
soreness of the lining membrane, laudanum or tincture of henbane 
may be added. Opium may be combined with the alteratives, 
especially where the diarrhoea still continues profuse. We have 
often found advantage in this state, from occasional very small 
doses (eight to ten grains) of sulphate of magnesia in some spiced 
water, combined with five or six drops of laudanum. Sometimes 
the nitric or sulphuric acid with laudanum effectually restrains the 
diarrhoea, and improves the character of the tongue, especially if 
there are aphthous ulcerations. The usual astringent remedies are 
inadmissible in the commencement, and only to be employed if the 
diarrhoea persist after the bowels have been cleared. The diet 
should be nourishing, but not stimulating, unless there is very great 
exhaustion. Arrow-root, gruel, broth, jelly, and other bland arti- 
cles, are the safest. Milk, with soda or Seltzer water, is very grate- 
ful to the patient in allaying thirst and keeping up power, especially 
where there is sickness. As the diarrhoea subsides, and the secre- 
tions become healthy, more nourishment may be taken; but any 
hurry in this respect, and any carelessness in the nature of the diet, 
often lead to relapses. Infusions of cascarilla or cinchona, with 
either ammonia or the mineral acids, may be tried in the convales- 
cent stage, and pure air will be then of great advantage. In cases 
where the head affection follows exhausting labours, with or with- 
out other signs of intestinal irritation, still greater caution is neces- 
sary in the treatment. In both, from a disposition to be too acutely 
alive to all ailments after parturition, there is often an eagerness to 
use active remedies, and especially to bleed. Such an error is pecu- 
liarly dangerous, and yet it is by no means uncommon in the class 
of cases we are now describing. A foul state of bowels aggravates 
the head affection, and however weak the patient may be, the judi- 
cious and cautious use of purgatives becomes absolutely necessary. 
The very distressing sensations about the head are best relieved by 
opium and camphor in full doses, and the alternation of these 



FALSE PERITONITIS. 593 

remedies with the purgatives is the principal point in the treatment. 
Cold applications to the head, and fomentations to the extremities, 
give much comfort to the patient, and produce repose. Nourish- 
ment is here of great importance; it should be of the lightest de- 
scription, and frequently given in small quantities ; as, though there 
is an exceedingly rapid digestion, from the natural effort to supply 
the loss which has been sustained, the power of the stomach has 
been much reduced, and the food should be that which will be most 
easily assimilated. 



D. FALSE PERITONITIS. 

There is a mild form of puerperal fever, first described by the 
late Dr. Gooch, the existence of which has been denied by some 
authors, but which has been prevalent at various times, and of which 
we have seen a great many instances. Mr. Hingeston has pub- 
lished several cases of it in the first volume of the Medical Gazette, 
and, more recently, Dr. Ferguson has given its history in his valua- 
ble work on puerperal fever. It seems to be the first stage of the 
more active inflammatory form, but, as if it stopped there, yielding 
to treatment which would have no great effect over acute inflamma- 
tion, and aggravated by active depletion, its morbid anatomy is not 
to be detected. In those cases which have died, death has either 
followed a more advanced stage of the disease, when inflammatory 
mischief has ensued upon the previous symptoms, or it has followed 
the use of too violent remedies, when no traces of disease sufficient 
to account for death could be detected on dissection. In many of 
these cases slight deposits of serum tinged with blood are often found 
in the serous cavities of the body, the result not of inflammatory 
action, as there is a pale and bleached state of membrane, but the 
consequence of over bleeding, which produces what Magendie 
calls a defibrinized state of the blood, when, its cohesive qualities 
being lost, it infiltrates through the tissues. This disease has been 
called "abdominal pain," which is its chief characteristic ; but such 
pains are so various, that such a name is by no means satisfactory. 
False peritonitis, a name by which it has been long known in our 
lying-in hospital, is open to objections ; but it is short, and will be 
less likely to mislead. The influence of the nervous system as well 
as the vascular in producing inflammation is acknowledged, and it 
would seem that in these cases the symptoms may be traced to that 
early condition in which the nerves of the peritoneum are chiefly 
affected, a certain degree of constitutional disturbance is produced, 
the balance is disturbed, but the vascular system has not yet been 
sufficiently excited to produce actual inflammation. In most of the 
epidemics of puerperal fever, this form has existed with the more 
formidable varieties, but it has now and then occurred to a very 
38 



594 SYMPTOMS. 

considerable extent, when the other forms of puerperal fever have 
been rare exceptions. 



I. SYMPTOMS. 

It is characterized by pain and tenderness of the abdomen, a 
slightly coated tongue, and a rapid, soft, compressible pulse; and 
though a rigor often precedes the attack, the skin is very little in- 
creased in temperature. Dr. Gooch remarks that such symptoms 
are most apt to occur when the patient, in her ordinary health, is 
delicate and nervous, or when there has been any irritating cause, 
such as severe gripings from purgatives, or unusually severe after 
pains from collection of coagula. An experienced practitioner will 
generally distinguish this mild form of puerperal fever by the soft- 
ness of the pulse, and by the absence of that peculiar anxiety of 
countenance which marks the more severe forms ; but if he were 
to be guided alone by the usual definitions of puerperal fever, viz., 
pain of the abdomen with tenderness and a rapid pulse, he would 
fall into serious error. The effect of remedies in these cases is most 
important, as diagnostic of their real character : bleeding produces 
little relief; if carried beyond a few ounces it accelerates, and (we 
believe) may cause the patient's death ; the blood shows no marks 
of inflammation, and the peritoneum or any of the pelvic or abdomi- 
nal viscera show no signs of disease. Fomentations, poultices, dia- 
phoretics, and opiates, soon remove the symptoms, and in general 
this is all that is necessary to be done, in addition to the exhibition 
of an occasional mild purgative. If in a doubtful case such reme- 
dies are tried, and yet the symptoms increase and become more 
formidable, we may be satisfied that the more active form of disease 
really exists, and we shall not find that the remedies from which 
we had hoped for relief will have done harm, or at all interfered 
with the efficiency of subsequent treatment. Sometimes such a 
mixed character of symptoms appears, that mild antiphlogistic treat- 
ment may be combined with the sedative and diaphoretic ; in such 
cases hydrargyria c. creta, or calomel, may be added to the opium, 
and James's powder, or Dover's powder ; and a few leeches may 
be also beneficially applied to the seat of the pain. 

The effect of nervous irritation and of mental emotion on the 
frame of a woman after delivery, often produces a collection of 
alarming symptoms, which have been classed as a distinct form of 
puerperal fever (the ataxic), by Tonnelle and Dr. Ferguson. 
We are obliged to confess, however, a great difficulty in such a 
distinction. The irritability of frame which leads to the anomalous 
symptoms described by these authors, 4s merely an accidental cir- 
cumstance. The chief characteristics are, sudden and alarming 
sinking, almost a total want of sleep, great restlessness, often ac- 
companied with delirium; a most anxious state of mind, with fear 



SYMPTOMS. 595 

of impending death ; and a pulse which is strikingly rapid, weak and 
irregular. Though there is sometimes no particular pain, there is 
generally acute pain in some part, principally in the abdomen, the 
hypogastrium, or the head. Upon a more careful investigation, 
however, we find that the pulse becomes more steady and tranquil 
under the influence of cheering looks and words of comfort, or by 
the attention of the patient being diverted from her malady. The 
locality of the pain also varies, and if there be tenderness, it is not 
always localized, the integuments of other parts of the body being 
very frequently equally sensitive. If we accidentally find the 
patient asleep, the pulse is scarcely beyond its natural quickness, 
and the respiration, previously hurried, is observed to be more 
regular and normal. If these cases are mistaken, and evacuations 
of blood and depleting remedies employed, the patient will suddenly 
sink, and on examination of the body, no lesions sufficient to ac- 
count for death are to be detected. The most effectual treatment 
consists in giving stimulants, if there be much exhaustion; nourish- 
ment at frequent intervals, and opium. In combination with cam- 
phor this remedy seems still more efficacious, and both should be 
given in large doses. From five to ten grains of camphor with one 
grain of either of the salts of morphia, will often in a few hours 
subdue every symptom of apparently formidable disease. 

The state of body in which such symptoms are apt to occur, is 
closely allied to, if not identical with, the hysterical condition ; 
which in women, under ordinary circumstances, so often produces, 
modifies and magnifies symptoms closely resembling serious organic 
diseases. By any one who is not conversant with the infinite vari- 
ety of these nervous or hysterical affections, there is great risk of 
mistakes being made ; and after childbirth, especially, symptoms 
often arise which simulate very remarkably real inflammation of 
almost every organ, but especially of the brain and the pelvic or 
abdominal viscera. The diagnostic signs are clearly laid down by 
Dr. Ferguson in his account of the ataxic form of puerperal fever ; 
and the appropriate treatment, as weil as the danger of mistaking 
the disease, forcibly insisted upon ; but we must decidedly consider 
it a fallacy to call this affection puerperal fever at all. Exactly as 
in hysteria, under ordinary circumstances, we find the sudden 
migration of the symptoms from the organ apparently affected, 
the great anxiety and alarm of the patient, the anomalous character 
of the attacks, and, above all, the beneficial effects of sedative reme- 
dies, and of the proper administration of nourishment and stimu- 
lants. Such cases are by no means uncommon ; they occur among 
the lower classes, most frequently in gin-drinkers and women of 
enfeebled constitutions, as well as in the nervous, excitable, and 
delicate of the higher ranks. They appear to us much more allied 
to puerperal mania than to puerperal fever, but they most nearly 
resemble hysteria. It must not be forgotten, however, that in such. 
an excitable state of the nervous system, real puerperal fever may 



596 MILK FEVER. 

arise ; but though it will be additionally difficult to recognize and to 
treat this combination, attention to the condition of the constitution 
we have to deal with will materially assist us in meeting the evil. 
It may be well to observe here, that while practitioners are often 
misled by the patient's alarm, which invariably aggravates the 
symptoms, they are not unfrequently led into error by their own 
fears. It has fallen to our lot on several occasions to witness this, 
and we have known serious injury resulting from being too pre- 
cipitate in treating disease which only existed in the mind of the 
medical attendant. Rigors often take place merely when the milk 
begins to flow ; tenderness of the hypogastrium, to some extent, 
will be found in most women, upon making any sudden or rough 
pressure for the first few days after delivery. Such symptoms are 
often inquired for by the practitioner, when his mind has been 
recently distressed by the loss of a patient after childbirth ; and 
being easily found, the judgment is unsettled, and disease is actually 
created by the treatment intended to avert it. It is very probable 
that many supposed cases of contagion might be explained in this 
manner. 

The existence of erysipelas in hospitals, or among the infants 
where the mothers have puerperal fever, has been long noticed. 
Many such coincidences have happened in the General Lying-in 
Hospital, and servants and nurses even have been often attacked. 
This has led some to consider the inflammation which occurs in 
puerperal peritonitis, &c, to be of an erysipelatous character. In 
those instances in which the morbid appearances consist chiefly of 
a copious serous effusion, this may perhaps be the case ; but we 
can hardly assent to this doctrine where firm lymph is deposited. 
The great resemblance between the effect of parturition on the 
cavity of the uterus, and what takes place after some important 
surgical operations, amputation for instance, as pointed out by 
Cruveilhier, would lead one to expect that erysipelas, so common 
in theiatter instances, would not be rare in the former. 



E. MILK FEVER. 

If under the head of puerperal fevers we are to include all the 
fevers to which lying-in women are liable, and that are peculiar to 
the puerperal state, we must not pass over what is commonly called 
milk fever. It is so entirely distinct, however, from those fevers 
which have been already described, that the consideration of it must 
be equally distinct. 



SYMPTOMS. TREATMENT. 597 



I. SYMPTOMS. 



In all women, about the third day after delivery, there is a degree 
of arterial and nervous disturbance resulting from the important 
process which is established at that period for the nourishment of 
the child. When the breasts begin to be distended with the lacteal 
secretion, there is often a slight shivering; the head feels oppressed 
or painful, the vision is confused, the sleep disturbed, the mind oc- 
casionally wanders, and there are thirst, a slight increase of the pulse 
and of the temperature of the skin ; but in a few hours these symp- 
toms gradually subside, and in numerous instances the disturbance 
is so slight, that it hardly attracts attention. But in other cases 
these symptoms are aggravated to an extent which often threatens 
the patient's life, and demands from the practitioner the most anx- 
ious attention. In these severe cases there is a well-marked pre- 
cursory rigor, followed by great pain and throbbing of the head, 
with much intolerance of light and sound ; the countenance is highly 
flushed; there are a contracted pupil and injected state of the conjunc- 
tiva ; the pulse is rapid, full, and hard ; the skin intensely hot and 
dry ; the thirst excessive ; and the tongue dry and coated. If such 
symptoms are not speedily alleviated, the milk is no longer secreted, 
the breasts become flaccid, the head symptoms become more severe, 
there is violent delirium, and meningitis is evidently established. It 
is a common expression in such cases, that " the milk flies to the 
head." It certainly happens in many, that on venesection the serum 
of the blood is found of a remarkably milky appearance; it is white 
and opaque, but without any creamy surface. These severe attacks 
may be generally traced to a too stimulating diet, a heated atmo- 
sphere, much exertion and disturbance in attempts to suckle, and 
still more frequently to mental agitation. They are much less fre- 
quent in modern times than formerly, when hot fires, crowded 
blankets, and brandy caudle, were the usual appendages to the 
lying-in chamber. 



II. TREATMENT. 

The remedies in the slighter forms of this disease may be limited, 
in general, to the free administration of saline draughts and diapho- 
retics, with purgatives which contain the neutral salts ; the milk 
should be gently drawn off, and the breasts fomented or poulticed; 
the room should be kept cool and well-ventilated; the most perfect 
quiet should be observed ; the mind should be soothed, and agitation 
or exertion carefully avoided ; the diet should be strictly antiphlo- 
gistic, and warm diluents plentifully supplied. A remission of the 
symptoms will then speedily take place, accompanied by a copious 



598 MILK FEVER. 

perspiration and tranquillity of pulse. In the more severe cases. 
when inflammation of the membrane of the brain is threatened or 
actually exists, the free use of the lancet is chiefly to be depended 
upon. Blood must be taken largely and in a full stream, to be 
repeated at intervals, according to the necessity of the case and the 
powers of the patient ; but in these attacks the loss of blood is 
generally borne well. Active purgatives, enemata, calomel in full 
and frequent doses, antimony, digitalis, and those remedies which 
depress the circulating power, will be valuable auxiliaries in sub- 
duing the violence of the symptoms. Fomentations should be 
applied to the breasts, and the child occasionally applied, as a means 
of re-exciting the secretion of milk. Cold evaporating lotions or 
ice may be kept constantly on the head, the hair being removed, 
and where the pain is very severe, and not readily relieved by the 
loss of blood from the arm, leeches or cupping-glasses may be 
applied to the head, or the temporal artery may be opened. In these 
cases many practitioners recommend blisters to the scalp, but 
our experience of them in that situation is not at all favourable, 
though we have often found benefit from their application to the 
legs, or to the nape of the neck. Applied to the scalp they have 
often seemed to increase the delirium and restlessness, and have not 
acted so favourably as the direct application of cold, the soothing 
effects of which have frequently been strikingly salutary. One of 
the earliest signs of recovery is the re-appearance of the milk in the 
breasts, and upon that taking place, the other symptoms usually 
improve with great rapidity. When, however, the progress of the 
disease is less favourable, and the remedies fail, symptoms of effusion 
either suddenly or gradually come on, and coma with dilated pupils, 
often terminating in convulsions, supervenes. On dissection, the 
usual results of acute inflammation of the brain are discovered. 

There are symptoms somewhat resembling those previously de- 
scribed, and arising from the same cause, lactification, which are also 
very common, but which are not inflammatory ; they are merely 
nervous, and not uncommonly end in one of the forms of puerperal 
mania. There are the same restlessness and want of sleep, wan- 
dering of mind, and rapidity of pulse ; but the skin is cooler than 
natural, and the pulse weak and irregular. There is readiness to 
start at the least noise, and an alarmed and anxious look, but sounds 
are not painful, and there is no dislike to the light. There may be 
headache, and confusion of ideas, but relief is readily obtained by 
keeping the head low and by soothing the mind. The milk retires, 
but it is gradually or irregularly returning at intervals. Such symp- 
toms usually follow anxiety or agitation of mind, undue fatigue in 
attempts to suckle, over-excitement of any description, or exhaustion 
from hemorrhage or from diarrhoea. In these cases opium and 
other narcotics in full doses, with camphor, will speedily calm the 



TREATMENT. 599 

distressing sensations, and recovery will be promoted and secured 
by care being taken to keep the patient perfectly quiet, and to re- 
move every cause of excitement and fatigue. If the convalescence 
be interrupted by the sucking of the infant, it should be at once dis- 
continued. 



INDEX 



Affusion, cold, in continued fever, 203. 

remittent, 446. 

scarlet, 563. 
Agminate glands in fever, (see Glands of 

Peyer,) 336. 
Ague, 272. 

complicated, 384. 

epidemic of Persia, 386. 

irregular, 282. 

quotidian, 278. 

quartan, 282. 

tertian, 279. 



B 



Black vomit, 329. 

Blood-letting in continued fever, 206. 

intermittent, 406. 

remittent, 441. 

yellow fever, 363. 
Brunner's glands, 

state of in remittent fever, 434. 

typhoid fever, 237. 



Chlorate of potash in continued fever, 225. 
Classification of Fevers, 73. 
Congestive Fever, 430. 

treatment, 447. 
Contagious origin of small-pox, 497. 
Continued Fever, 74. 

anatomical characters, 149. 

causes, 159. 

convalescence, 230. 

duration, 14S. 

eruptions in, 124. 

mortality of, 142. 

prevalence, 139. 

prognosis, 194. 

prophylaxis, 232. 

relapses, 135. 

saline treatment of, 200. 

secondary affections in, 113. 

sequels, 133. 

symptoms, 74. 

varieties of, 29. 
Convalescence after continued fever, 148. 

treatment of, 230. 

typhoid fever, 249. 
39 



Definition of Fever, 17. 



Ectrotic treatment of small-pox, 506. 
Epidemic synocha, 

of Scotland in 1843, 87. 
anatomical characters, 90. 
history, 96. 
nature, 93. 
prognosis, 92. 
sequelae, 90. 

state of the blood in, 91. 
symptoms, 87. 
at Philadelphia Hospital in 1844, 99. 
at Val de Grace, Paris, 1844, 99. 
Epidemic origin of small-pox, 499. 
Ephemeral Fever, 
causes, 75. 
definition of, 75. 
diagnosis, 76. 
prognosis, 76. 
symptoms, 75. 
treatment, 76. 
Eruptive Fevers, 71. 
exanthematous fevers, 71. 



Fainting fever of Persia, 386. 
Febris variolosa sine eruptione, 486. 
Fever, 

congestive, 430. 

continued, 74. 

eruptive, 71. 

exanthematous, 71. 

fainting, 386. 

gastric remittent, 448. 

Hungarian, 415. 

infantile remittent, 448. 

intermittent, 372. 

long, 234. 

Mediterranean, 415. 

nervous, 234. 

putrid, 234. 

puerperal, 570. 

remittent, 415. 

remittent of children, 448 

seasoning, 84. 

slow, 234. 



602 



INDEX. 



Fever — Continued. 

typhous, 100, 234. 

typhoid, 234. 

typhus, 102. 

Walcheren, 415. 

yellow, 314. 
Forms of fever, 29. 



Gastric Remittent Fever, (see Infantile 

Gastric Remittent Fever,) 448. 
General Doctrines of Fever, 17. 
Glands in fever, 
agminate, 235. 
Brunner's, 

in continued fever, 237. 
in remittent, 434. 
isolated, 237. 
mesenteric, 237. 
Peyer's, 

in typhoid fever, 235. 
in remittent fever, 434. 
in scarlet fever, 559. 



Hectic Fever, 
causes, 465. 
definition, 462. 
diagnosis, 465. 
infantile, 448. 
symptoms, 462. 
treatment, 467. 



Infantile Gastric Remittent Fever, 448. 
acute, 449. 

causes, 452. 

prognosis, 453. 

symptoms, 449. 

treatment, 455. 
chronic, 457. 

symptoms, 457. 

treatment, 459. 
Infection, laws of, 164. 
Inflammatory Fever, 
causes, 83. 
convalescence in, 81. 
definition of, 78. 
diagnosis, 82. 
epidemic in Scotland, 87. 
prognosis, 83. 
relapses after, 135. 
state of the blood in, 79. 
symptoms, 78. 
treatment, 83. 
Inoculation, 

of measles, 541. 
variolous, 510. 
practice of, 513. 
value of, 515. 
Intermittent Fever, 
algid, 392. 



Intermittent Fever — Continued. 

anatomical characters, 397. 

bleeding, 406. 

blood in, 403. 

comatose, 390. 

complications of, 388. 

congestive, 385. 

definition, 272. 

diagnosis, 393. 

exciting causes, 404. 

malignant, 385. 

nature of, 403. 

prognosis, 394. 

pernicious, 386. 

quinine in, 413. 

statistics of, 399. 

symptoms, 373. 

treatment, 405. 

varieties, 378. 
Iodine, tincture of, in small-pox, 508. 
Isolated glands, (see Brunner's Glands,) 237. 



Local diseases in fever, 38. 

Long Fever, 237. 

Low fever of children, 448. 



M 



Maculated eruption in fever, 125. 
Measles, 

anatomical characters, 538. 

blood in, 538, 

causes, 554. 

complications, 536. 

diagnosis, 539. 

malignant, 536. 

prognosis, 539. 

sequelae, 527. 

symptoms, 532. 

treatment, 543. 
Measly eruption in fever, 125. 
Mercurial ointment in small-pox, 507. 
Mesenteric glands, 237. 
Mesenteric Fever, 448, 
Milk Fever, 596. 



N 

Nature of fever, 39. 
Nervous Fever, 234. 
Neuralgia, 136. 



(Edema, 137. 
Opium in fever, 220. 



Petechia;, 124. 



INDEX. 



6oa 



Peritonitis. 

Acute puerperal, 577. 

false, 593. 
Plague, 

anatomical characters, 283. 

blood in, 275. 

causes, 299. 

complications, 282. 

definition, 268. 

diagnosis, 288. 

nature, 296. 

mortality, 293. 

prognosis, 289. 

prophylaxis, 309. 

sequelae, 282. 

statistics, 290. 

symptoms, 268. 

treatment, 310. 

varieties, 276. 
Puerperal intestinal irritation, 589. 
Puerperal Fevers, 570. 

predisposing causes, 573. 

adynamic or malignant, 581. 
symptoms, 581. 
morbid appearances, 583. 
treatment, 585. 
nature, 583. 
Putrid Fever, 234. 



It 



Remittent Fever. 

anatomical characters, 433. 

bilio-inflammatory, 422. 

complications, 431. 

congestive, 430. 

definition, 415. 

diagnosis, 438. 

duration, 435. 

gastric, 448. 

infantile, 448. 

inflammatory, 424. 

liver in, 433. 

malignant, 427. 

nature, 437. 

pernicious, 427. 

prognosis, 435. 

symptoms, 416. 

terminations, 432. 

treatment, 439. 

varieties, 422. 
Rheumatism in fever, 136. 
Recurrence to the cow for primary lymph, 

524. 
Revaccination, 526, 
Rubeola, (see Measles.) 

malignant, 536. 

sine catarrho, 534. 

vulgaris, 532. 



S 



Saline treatment of fever, 225. 
Scarlatina, (see Scarlet Fever,) 546. 

anginosa, 549. 

maligna, 551. 



Scarlatina — Continued. 

simplex, 547. 

sine exanthemate, 553. 
Scarlet Fever, 546. 

anatomical characters, 558- 

anginose, 549. 

blood in, 557. 

causes, 559. 

diagnosis, 561. 

malignant, 551. 

mortality, 561. 

prognosis, 561. 

prophylaxis, 568. 

sequela?, 553. 

simple, 547. 

symptoms, 547. 

varieties, 546. 

treatment, 563. 
Scarlatinal Dropsy, 554. 

treatment of, 568. 
Small-pox, 

anatomical characters, 493. 

anomalous, 484. 

blood in, 492. 

causes, 497. 

confluent, 475. 

contagious origin of, 497. 

definition, 469. 

discrete, 470. 

diagnosis, 487. 

epidemic origin of, 499. 

eruptive fever in, 470. 

incubation, 470. 

maturation, 471. 

malignant, 483. 

mitigated confluent, 485. 

mortality, 490. 

prognosis, 488. 

recurrent, 501. 

semiconfluent, 482. 

susceptibility of, 500. 

symptoms, 475. 

treatment, 502. 

varicelloid, 486. 

without eruption, 486. 
Spleen, 

in intermittent fever, 392. 

yellow fever, 341. 

typhus, 155. 

typhoid fever, 238. 
Stevens, Dr., his saline treatment of fever, 

225. 
Stomach fever, 448. 
Svnocha, (see Inflammatory Fever.) 

of hot climates, 84. 
Synochus, (see Typhoid Fever,) 101. 



Typhoid Fever, 

anatomical characters, 
blood in, 243. 
causes, 255. 
complications, 251. 
convalescence, 244. 
definition, 234. 



235. 



604 



INDEX. 



Typhoid Fever — Continued. 

differential diagnosis, 252. 

duration, 250. 

identity of, with typhus, 259. 

march, 250. 

mortality, 254. 

of children, 266. 

prognosis, 254. 

recurrence, 251. 

relapses, 251. 

symptoms, 239. 

treatment, 256. 

urine in, 249. 
Typhous Fever, (see Synocha and Typhoid 

Fever.) 
Typhus, 

anatomical characters, 149. 

blood in, 112. 

causes, 159. 

contagion, 165. 

convalescence in, 110, 230. 

definition, 102. 

duration, 148. 

eruptions in, 125. 

history, 103. 

identity of, with typhoid, 259. 

mortality, 144. 

prevalence, 140. 

prognosis, 141. 

prophylaxis, 232. 

relapses, 134. 

saline treatment in, 225. 

sequelae, 133. 

secondary affections in, 113. 

symptoms, 104. 

treatment, 200. 



Vaccination, 518. 

history of, 518. 

phenomena of, 521. 

theory, 523. 
Variola, (see Small-pox.) 

benigna discreta, 470. 

confluens, 475. 

confluens mitigata, 485. 

corymbosa, 483. 

maligna, 483. 

semi-confluens, 482. 

sine eruptione, 486. 

varicelloides, 486. 
Variolar anomalre, 484. 
Variolous vesicle, 

anatomical characters of, 473. 



Yellow Fever, 

anatomical characters, 334. 
at Dominica, 327. 
at Galveston, 327. 
at Gibraltar, 324. 
causes, 352. 
definition, 314. 
diagnosis, 346. 
nature, 349. 
non-contagious, 360. 
prognosis, 344. 
statistics, 341. 
symptoms, 315. 
treatment, 363. 



THE END. 



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LEA & BLANCHARD'S PUBLICATIONS. 



THE GREAT MEDICAL LIBRARY, 



NOW RSikDY. 

THE 

CYCLOPEDIA OF PRACTICAL MEDICINE, 

COMPRISING 

TREATISES ON THE 
NATURE AND TREATMENT OF DISEASES, 

MATERIA MEDICA AND THERAPEUTICS, 
DISEASES OF WOMEN AND CHILDREN, 

MEDICAL JURISPRUDENCE, &C. &C. 

EDITED BY 

JOHN FORBES, xW.D., F.R.S., 
ALEXANDER TWEEDIE, M.D., F.R.S., 

AND 

JOHN CONOLLY, M.D. 

REVISED, WITH ADDITIONS, 
By ROBLEY DUNGLISON, M. D. 



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This excellent work has now been before the profession for a short 
time, and has met with universal approbation as containing a vast body of 
information on all points connected with Practical Medicine. To physi- 
cians residing at a distance from Medical libraries, or the means of procu- 
ring works of reference, it will prove almost invaluable, as a work to be 
constantly consulted. That the extent of it may be properly understood, 
the publishers append a list of the contents. It will be seen that one of the 
peculiar advantages of this work is that every subject has been treated by 
an author whose attention has been directed peculiarly to that branch, the 
most eminent physicians of Great Britain having joined in the production 
of the whole; while the numerous additions of Dr. Dunglison have 
brought the work up to the very day of publication and with reference 
particularly to American practice. 



LEA & BLANCHARD'S PUBLICATIONS. 



Cyclopssdia of Practical Medicine, continued. 



CONTENTS OF VOLUME I. 



Abdomen, Exploration of the, Dr. 
Forbes. 

Abortion, Dr. Lee. 

Abscess, Internal, Dr. Tweedie. 

Abstinence. Dr. Marshall Hall. 

Achor, Dr. Todd. 

Acne, Dr. Todd. 

Acrodynia, Dr. Dunglison. 

Acupuncture, Dr. Elliotson. 

Age, Dr. Roget. 

Air, Change of, Sir James Clarke. 

Alopecia, Dr. Todd. 

Alteratives, Dr. Conolly. 

Amaurosis, Dr. Jacob. 

Amenorrhoea, Dr. Locock. 

Anaemia, Dr. Marshall Hall. 

Anasarca, Dr. Darwall. 

Angina Pectoris, Dr. Forbes. 

Anodynes, Dr. Whiting. 

Anthelmintics, Dr. A.T. Thomson. 

Anthracion, Dr. Dunglison. 

Antiphlogistic Regimen, Dr. Barlow. 

Antispasmodics, Dr. A. T.Thomson. 

Aorta, Aneurism of, Dr. Hope. 

Apoplexy, Cerebral, Dr. Clutterbuck. 
" Pulmonary, Dr. Town- 
send. 

Arteritis, Dr. Hope. 

Ascites, Dr. Darwall. 

Artisans, Diseases of, Dr. Darwall. 

Asphyxia, Dr. Roget. 

" of the New Born, Dr. Dun- 
glison. 

Asthma, Dr. Forbes. 

Astringents, Dr. A. T. Thomson. 

Atrophy, Dr. Townsend. 

Auscultation, Dr. Forbes. 

Barbiers, Dr. Scott. 

Bathing, Dr. Forbes. 

Beriberi, Dr. Scott 



Blood, Determination of. Dr. Barlow. 
" Morbid States of, Dr. Marshall 
Hall. 

Blood-letting, Dr. Marshall Hall. 

Brain, Inflammation of the, 

Meningitis, Dr. Quain. 
Cerebritis, Dr. Adair Craw- 
ford. 

Bronchial Glands, Diseases of the, 
Dr. Dunglison. 

Bronchitis, Acute and Chronic, Dr. 
Williams. 
" Summer, Dr. Dunglison. 

Bronchocele, Dr. And. Crawford. 

Bulla*, Dr, Todd. 

Cachexia, Dr. Dunglison. 

Calculi, Dr. T. Thomson. 

Calculous Diseases, Dr. Cumin. 

Catalepsy, Dr. Joy. 

Catarrh, Dr. Williams. 

Cathartics, Dr. A. T. Thomson. 

Chest, Exploration of the, Dr. Forbes. 

Chicken Pox, Dr. Gregory. 

Chlorosis, Dr. Marshall Hall. 

Cholera, Common and Epidemic, Dr. 
Brown. 
" Infantum, Dr. Dunglison. 

Chorea, Dr. And. Crawford. 

Cirrhosis of the Lung, Dt. Dunglison. 

Climate, Dr. Clark. 

Cold, Dr. Whiting. 

Colic, Drs. Whiting and Tweedie. 

Coliea Pictonum, Dr. Whiting. 

Colon, Torpor of the, Dr. Dunglison 

Coma, Dr. Adair Crawford. 

Combustion, Spontaneous, Dr. Ap- 
john. 

Congestion of Blood. Dr. Barlow. 

Constipation, Drs. Hastings and 
Streeten. 



Contagion. Dr. Brown. 
Convalescence, Dr Tweedie. 
Convulsions, Dr. Adair Crawford. 

" Infantile, Dr. Locock. 

" Puerperal, Dr. Locock. 

Coryza, Dr. Williams. 
Counter Irritation, Dr. Williams. 
Croup, Dr. Cheyne. 
Cyanosis, Dr Crampton. 
Cystitis, Dr. Cumin. 
Dead, Persons found, Dr. Beatty. 
Delirium, Dr. Pritchard. 

" Tremens, Drs. Carter and 
Dunglison . 
Dengue, Dr. Dunglison. 
Dentition, Disorders of, Dr. Joy. 
Derivation. Dr. Stokes. 
Diabetes, Dr. Bardsley. 
Diagnosis, Dr. Marshall Hall. 
Diaphoretics, Dr. A. T. Thomson. 
Diarrhoea, Drs. Crampton and Forbes. 

" Adipous, Dr. Dunglison. 

Dietetics, Dr. Paris, 
Disease, Dr. Conolly. 
Disinfectants, Dr. Dunglison. 
Disinfection. Dr. Brown. 
Diuretics, Dr. A. T.Thomson. 
Dropsy, Dr. Darwall. 
Dysentery, Dr. Brown. 
Dysmenorrhcea, Dr. Locock. 
Dysphagia, Dr. Stokes. 
Dyspncea, Dr. Williams. 
Dysuria, Dr. Cumin. 
Ecthyma. Dr. Todd. 
Eczema, Dr. Joy. 
Education, Physical, Dr. Barlow. 
Electricity. Dr. Apjohn. 
Elephantiasis, Dr, Joy. 
Emetics, Dr. A. T. Thomson. 
Emmenagogues, Dr. A. T. Thomson 



CONTENTS OF VOLUME II. 



Emphysema, Dr. R. Townsend. 
" of the Lungs, Dr. R. 

Townsend. 
Empyema, Dr. R. Townsend. 
Endemic diseases, Dr. Hancock. 
Enteritis, Drs. Stokes and Dunglison. 
Ephelis, Dr. Todd. 
Epidemics, Dr. Hancock. 
Epilepsy, Dr. Cheyne. 
Epistaxis, Dr. Kerr. 
Erethismus Mercurialis, Dr. Burder. 
Erysipelas, Dr. Tweedie. 
Erythema, Dr. Joy. 
Eutrophic, Dr. Dunglison. 
Exanthemata, Dr. Tweedie. 
Expectorants, Dr. A. T. Thomson. 
Expectoration, Dr. Williams. 
Favus, Dr. A. T. Thomson. 
Feigned diseases, Drs. Scott, Forbes 

and Marshall. 
Fever, general doctrine of, Dr. Twee- 
die. 

" Continued, and its modifica- 
tions, Dr. Tweedie. 

" Typhus, Dr. Tweedie. 

" Epidemic Gastric,iDr. Cheyne. 

" Intermittent, Dr. Brown. 

" Remittent, Dr. Brown. 

u Malignant Remittent, Dr. Dun- 
glison. 



Fever, Infantile, Dr. Joy. 

" Hectic, Dr Brown. 

" Puerperal, Dr. Lee. 

" Yellow, Dr. Gilkrest. 
Fungus Haematodes, Dr. Kerr. 
Galvanism, Drs. Apjohn and Dungli- 
son. 
Gastritis, Dr. Stokes. 
Gastrodynia, Dr. Barlow, 
Gastro-Enteritis, Dr. Stokes. 
Glanders, Dr. Dunglison. 
Glossitis, Dr. Kerr. 
Glottis, Spasm of the, Dr. Joy. 
Gout, Dr. Barlow. 
Haematemesis, Dr. Goldie. 
Haemoptysis, Dr. Law. 
Headache, Dr. Burder. 
Heart, Diseases of the, Dr. Hope. 

" Dilatation of the, Dr. Hope. 

" Displacement of the, Dr. 
Townsend. 

" Fatty and greasy degenera- 
tion of the, Dr. Hope. 

" Hypertrophy of the, Dr. Hope. 

" Malformations of the, Dr. Wil- 
liams. 

" Polypus of the, Dr. Dunglison. 

" Rupture of the, Dr. Townsend. 

" Diseases of the "Valves of the, 
Dr. Hope. 



Haemorrhage, Dr. Watson. 
Haemorrhoids, Dr. Burne. 
Hereditary Transmission of Disease, 

Dr. Brown. 
Herpes, Dr. A. T. Thomson. 
Hiccup, Dr. Ash. 
Hooping Cough. Dr. Johnson. 
Hydatids, Dr. Kerr. 
Hydrocephalus, Dr. Joy. 
Hydropericardium, Dr. Darwall. 
Hydrophobia, Dr. Bardsley. 
Hydrothorax, Dr. Darwall. 
Hyperaesthesia, Dr. Dunglison. 
Hypertrophy, Dr. Townsend. 
Hypochondriasis, Dr. Pritchard. 
Hysteria. Dr. Conolly. 
Ichthyosis, Dr. Thomson. 
Identity, Dr. Montgomery. 
Impetigo, Dr. A. T. Thomson. 
Impotence, Dr. Beatty. 
Incubus, Dr. Williams. 
Indigestion, Dr. Todd. 
Induration, Dr. Carswell. 
Infanticide, Dr. Arrowsmith. 
Infection, Dr. Brown. 
Inflammation, Drs. Adair Crawford 

and Tweedie. 



Influenza, Dr. Hancock. 
Insanity, Dr. Pritchard. 
Intussusception, Dr. Dunglison. 
Irritation, Dr. Williams. 
Jaundice, Dr. Burder. 

" of the Infant, Dr. Dunglison. 
Kidneys, diseases of, Dr. Carter. 
Lactation, Dr. Locock. 
Laryngitis, Dr. Cheyne. 

" Chronic, Dr. Dunglison. 

Latent diseases, Dr. Christison. 



CONTENTS OF VOLUME III. 

Lepra, Dr. Houghton. Medicine, State of in the 19th Cen- 

Leucorrhcea, Dr. Locock. tury, Dr. Alison. 

Lichen, Dr. Houghton. " Practical, Principles of, 

Liver, Diseases of the, Dr. Stokes. Dr. Conolly. 

Liver, Diseases of the, Dr. Venables. Melaena, Dr. Goldie. 
" Inflammation of the, Dr. Melanosis, Dr. Carswell. 

Stokes. Menorrhagia, Dr. Locock. 

Malaria and Miasma, Dr. Brown. Menstruation, Pathology of, Dr. Lo- 
Medicine, History of, Dr. Bostock. cock. 

" American, before the Re- Miliaria, Dr. Tweedie. 

volution, Dr. J. B. Beck. Milk Sickness, Dr. Dunglison. 



LEA & BLANCHARD'S PUBLICATIONS. 



Cyclopaedia of Practical Medicine, continued. 
CONTENTS OF VOLUME III —Continued. 

Mind, Soundness and Unsoundness Pancreas, diseases of the, Dr. Carter. Pneumothorax, Dr. Houghton. 

of, Drs. Pritchard andDunglison. Paralysis, Dr. Todd. Porrigo, Dr. A. T. Thomson. 

Molluscum, Dr. Dunglison. Parotitis, Dr. Kerr. Pregnancy and Delivery, signs of, 

Mortification, Dr. Carswell, Parturients, Dr. Dunglison. Dr. Montgomery. 

Narcotics, Dr. A. T. Thomson. Pellagra, Dr. Kerr. Prognosis, Dr. Ash. 

Nauseants, Dr. Dunglison. Pempliigus, Dr. Corrigan. Prurigo, Dr. A. T. Thomson. 

Nephralgia and Nephritis, Dr. Carter. Perforation of the Hollow Viscera, Pseudo-Morbid. Appearances, Dr. 
Neuralgia, Dr. Elliotson. Dr. Carswell. Todd. 

Noli-Me-Tangere or Lupus, Dr. Pericarditis, Dr. Hope. Psoriasis, Dr. Cumin. 

Houghton. Peritonitis, Drs. Mc Adam and Stokes. Ptyalism, Dr. Dunglison. 

Nyctalopia, Dr Grant. Phlegmasia Dolens, Dr. Lee. Puerperal Diseases, Dr. Marshall 

Obesity, Dr. Williams. Pityriasis, Dr. Cumin. Hall. 

(Edema, Dr. Darwall. Plague, Dr. Brown. Pulse, Dr. Bostock. 

Ophthalmia, Drs. Jacobs and Dungli- Plethora, Dr. Barlow." Purpura, Dr. Goldie. 

son. Pleurisy, Dr. Law. Pus, Dr. Tweedie. 

Otalgia and Otitis, Dr. Burne. Plica Polonica, Dr. Corrigan. Pyrosis, Dr. Kerr. 

Ovaria, Diseases of the, Dr. Lee. Pneumonia, Dr. Williams. Rape, Dr. Beatty. 

Palpitation, Drs. Hope andDunglison. 

CONTENTS OF VOLUME IV. 

Refrigerants, Dr. A. T. Thomson. Statistics, Medical, Drs. Hawkins Toxicology, Drs. Apjohn and Dungli- 
Rheurnatism, Drs. Barlow and Dun- and Dunglison. son. 

glison. Stethoscope, Dr. Williams. Transformations, Dr. Duesbury. 

Rickets, Dr. Cumin. Stimulants, Dr. A. T. Thomson. Transfusion. Dr. Kay. 

Roseola, Dr. Tweedie. Stomach, Organic Diseases of, Dr. Tubercle, Dr. Carswell. 

Rubeola, Dr. Montgomery. Houghton and Dunglison. Tubercular Phthisis, Sir James Clark. 

Rupia, Dr. Corrigan. Stomatitis, Dr. Dunglison. Tympanitis, Dr. Kerr. 

Scabies, Dr. Houghton. Strophulus, Dr. Dunglison. Urine, Incontinence of, Dr. Cumin. 

Scarlatina, Dr. Tweedie. Succession of Inheritance, Legitima- Urine, Suppression of, Dr. Carter. 

Scirrhus, Dr. Carswell. ey, Dr. Montgomery, Urine, Morbid States of, Dr. Bostock. 

Scorbutus, Dr. Kerr. Suppuration, Dr. Todd. Urine, Bloody, Dr. Goldie. 

Scrofula, Dr. Cumin. Survivorship, Dr. Beatty. Urticaria, Dr. Houghton. 

Sedatives, Drs. A. T. Thomson and Sycosis, Dr. Cumin. Uterus, Pathology of, Dr. Lee. 

Dunglison. Symptomalology, Dr. Marshall Hall. Vaccination, Dr. Gregory. 

Sex, Doubtful, Dr. Beatty. Syncope, Dr. Ash. Varicella, Dr. Gregory. 

Small Pox, Dr. Gregory. Tabes Mesenterica, Dr. Joy. Veins, Diseases of, Dr. Lee. 

Softening of Organs, Dr. Carswell. Temperament, Dr. Pritchard. Ventilation, Dr. Brown. 

Somnambulism and Animal Magne- Tetanies, Dr. Dunglison. Wakefulness, Dr. Cheyne. 

tism, Dr. Pritchard. Tetanus, Dr. Symonds. Waters Mineral, Dr. T.Thompson. 

Spermatorrhosa, Dr. Dunglison. Throat, Diseases of the, Dr. Tweedie. Worms, Dr. Joy. 

Spinal Marrow, Diseases of the, Dr. Tissue Adventitious. Yaws, Dr. Kerr.J 

Todd. Tonics, Dr. A. T. Thomson. Index, &c. 

Spleen, Diseases of the, Drs. Bigsby, Toothache, Dr. Dunglison. 

and Dunglison. 



The Publishers wish it to be particularly understood that this work not 
only embraces all the subjects properly belonging to 

PRACTICAL MEDIGINEj 

but includes all the diseases and treatment of 

WOMEN AND CHILDREN, 

as well as all of particular importance on 

MATERIA MEDICA, THERAPEUTICS, 

AND 

MEDICAL JURISPRUDENCE, ' 

Thus presenting important claims on the profession from the greater 
extent of subjects embraced in this than in other works on the mere 
Practice of Medicine; while, notwithstanding its BEAUTIFUL 
EXECUTION, its REMARKABLE CHEAPNESS places it 
within the reach of all. 



LEA & B LAN CHARD'S PUBLICATIONS. 



Cyclopedia of Practical Medicine, continued. 



The Publishers present- a few of the notices which the work has received 
from the press in this country and in England. 



"We rejoice that this work is to be placed within 
the reach of the profession in this country, it being 
unquestionably one of very great value to the practi- 
tioner. This estimate of it has not been formed from 
a hasty examination, but after an intimate acquaint- 
ance derived from frequent consultation of it during 
the past nine or ten years. Thefdi'ors are praciiiion-. 
ers of established reputation, and 1 he list of contribu- 



great extent and usefulness."— Dr. Barloic-s Address 
to the Med. and Sur. Association. 

" For reference, it is above all price to every practi- 
tioner." — The Western Lancet. 

"This Cyclopedia is pronounced on all hands to be 
one of the most valuable medical publications of lhe 
day. It is meant to be a library of Practical Medicine. 
As a work of reference it is invaluable. Among the 



tors embraces many of the mosi. eminent professors contributors to its pages, it numbers many of the most 



and teachers of London, Edinburgh, Dublin and Glas- 
gow. It is, indeed, the great merit of this work that 
the principal articles have been furnished by practi- 
tioners who have not only devoted especial attention 
to the diseases about which they have written, but 
have also enjoyed opportunities for an extensive prac- 
tical acquaintance with them, and whose reputation 
carries the assurance of their competency justly to 
appreciate the opinions of others, while it stamps their 
own doctrines with high and just authority."— Ameri- 
can Medical Journal. 

"Do young physicians generally know what a trea- 
sure is offered to them in Dr. Dunglison's revised edi- 
tion? Without wishing to be thought importunate, we 
cannot very well refrain from urging upon them the 
claims of this highly meritorious undertaking." — Bos- 
ton Medical and Surgical Journal:. 

" It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most 
advantageous light, and with adaptations to various 
tastes and expectations."— Medical Examiner. 

"Such a work as this has long been wanting in this 
country. British medicine ought to have set itself 
forth in this way much sooner. We have often won- 
dered that the medical profession and- the enterprising 
publishers of Great Britain did not, long ere this, 
enter upon such an undertaking as a Cyclopedia of 
Practical Medicine."— London Medical Gazette. 

"It is what it claims to be, a Cyclopedia, in which 
Practical Medicine is posted up to the present day, 
and as such constitutes a storehouse of medical know- 
ledge upon which the student and practitioner may 
draw with equal advantage."— The Western Journal 
of Medicine and Surgery. 

"The Cyclopedia of Practical Medicine, a work 
which does honour to our country, and to which one 
is proud to see the names of so many provincial phy- 
sicians attached." — Dr. Hastings' Address to Pro- 
vincial Medical and Surgical Association. 

"Of the medical publications of the past year, one 
may be more particularly noticed, as partaking, from 
its extent and the number of contributors, somewhat 
of the nature of a national undertaking, namely, the 



experienced and learned physicians of the age, and as 
a whole it forms a compendium of medical science 
and practice from which practitioners and students 
may draw the richest instruction ''— Western Journ. 
of Med. and Surgery. 

"The contributors are very numerous, including 
the most distinguished physicians in the kingdom. 
The design of the work embraces practical articles of 
judicious length in Medicine, Therapeutics, Hygiene, 
&c, so that, within a small compass, and of easy re- 
ference, the student possesses a complete library, 
composed of the highest authorities*. To the country 
practitioner, especially, a publication of this kind is 
of inestimable value."— U. S. Gazette. 

" When it is considered that this great work em- 
braces three hundred original essays, from sources of 
the highest authority, we cannot but hope that our 
medical friends will offer all the requisite encourage- 
ment to the publishers." — Boston Medical and Sur- 
gical Journal. 

"In our last number we noticed the publication of 
this splendid work by Lea & Blanchard. We have 
since received three additional parts, an examiaation 
of which has confirmed us in our first impression, that 
as a work of reference for the practitioner— as a Cyclo- 
paedia of Practical Medicine— it is admirably adapted 
to the wants of the American profession. In fact, it 
might advantageously find a place in the library of 
any gentleman, who has leisure and taste for looking 
somewhat into the nature, causes, and cure of dis- 
eases."— Western Journal of Med. and Surgery. 

"The favourable opinion which we expressed on 
former occasions from the specimens then before us, 
is in no degree lessened by a further acquaintance 
with its scope and execution."— Medical Examiner. 

"The Cyclopedia must be regarded as the most 
complete work of Practical Medicine extant; or, at 
least in our language. The amoant of information on 
every topic which it embraces, is posted up to the 
present time ; and so far as we are able to judge, it is 
generally more free from natural exclusiveness and 
prejudices, than is usually the case with British pub- 
lications. The getting up of the American edition is 
very creditable to the Publishers. It will compare very 



Cyclopedia of Practical Medicine.' It accomplishes favourably with the English edition. In some re 



what has been noticed as most desirable, by present 
ing, on several important topics of medical inquiry, 
full, comprehensive, and well digested expositions, 
showing the present state of our knowledge on each. 
In this country, a work of this kind was much wanted: 
and that now supplied cannot but be deemed- an im- 
portant acquisition. The difficulties of the undertak- 
ing were not slight, and it required great energies to 
surmount them. These energies, however, were pos- 
sessed by the able and distinguished editors, who, 
with diligence and labour such as few can know or 



spects, it is much to be preferred. During the original 
publication, many of the articles not being in readi- 
ness to be printed in proper alphabetical order, it be- 
came necessary to include them together in a single 
volume, as a supplement to the work. This difficulty 
is obviated in the American edition. On the whole, 
we advise those who desire a compendious collection 
of the latest and most important information in the 
various departments of Practical Medicine, including 
Midwifery, Materia Medica, Medical Jurisprudence, 
&c, to possess themselves of this work."— The Bvf- 



appreciate, have succeeded in concentrating in a work falo Medical Journal 
of moderate size, a body of practical knowledge of 

%* In reply to the numerous inquiries made to them respecting Tweedie's Library of Practical 
Medicine, the Publishers beg leave to state that its place is supplied, in a great measure, by the 
Cyclopaedia of Practical Medicine, a work much more extended in its plan and execution. The 
works are entirely distinct and by different authors. The " Library"consists of essays on diseases, 
systematically arranged. The " Cyclopaedia" embraces these subjects treated in a more extended 
manner, together with numerous interesting essays on all important points of Medical Jurispru- 
dence, Materia Medica, Therapeutics, Diseases of Women and Children, History of Medicine, &c, 
&c, by the first physicians of England, the whole arranged alphabetically for easier reference. 



LEA & BLANCHARD'S PUBLICATIONS. 



WATSON'S PRACTICE. 

NEW AND IMPROVED EDITION. 



Now Ready, 
LECTURES 



ON THE 

PRINCIPLES AND PRAGTIGE OF PHYSIC 

DELIVERED AT KING'S COLLEGE, LONDON. 

By THOMAS WATSON, M. D., &c. &c. 

SECOND AMERICAN, FROM THE SECOND LONDON EDITION. 

REVISED ; WITH ADDITIONS, 

By D. FRANCIS CONDIE, M. D., 

Author of a work on the "Diseases of Children," &c. 

In one Octavo Volume. 
Of nearly eleven hundred large pages, strongly bound with raised bands. 

The rapid sale of the first edition of this work is an evidence of its 
merits, and of its general favour with the American practitioner. To 
commend it still more strongly to the profession, the publishers have gone 
to a great expense in preparing this edition with larger type, finer paper, 
and stronger binding, with raised bands. It is edited with reference par- 
ticularly to American practice, by Dr. Condie ; and with these numerous 
improvements, the price is still kept so low as to be within the reach of 
all, and to render it among tne cheapest works offered to the profession. 
It has been received with the utmost favour by the medical press, both 
of this country and of England, a few of the notices of which, together 
with a letter from Professor Chapman, are submitted. 

"We know of no work better calculated for being " We find that, from the great length we have gone 
placed in the hands of the student, and for a text book, in our analysis of this work, we must close our notice 
and as sucli we are sure it will be very extensively of it here for the present — not, however, without ex- 
adopted. On every important point the author seems pressing our unqualified approbation of the manner in 
to have posted up his knowledge to the day."— Ameri- which the author has performed his task. But it is as 
can Medical Journal. a book of elementary instruction that we admire Dr. 

•'In the Lectures of Dr. Watson, now republished Watson's vjoxk.^—Medico-Chirurgical Review. 
here in a large and closely-printed volume, we have "One of the most practically useful books that ever 
a body of doctrine and practice of medicine well cal- was presented to the student— indeed a more admira- 
culated, by its intrinsic soundness and correctness of ble summary of general and special pathology, and of 
style, to instruct the student and younger practitioner, the application of therapeutics to diseases, we are free 
and improve members of the profession of every age." to say has not appeared for very many years. The 
— Bulletin of Medical Science. lecturer proceeds through the whole classification of 
" We regard these Lectures as the best exposition human ills, a capite ad calcem, showing at every step 
of their subjects of any we remember to have read, an extensive knowledge of his subject, with the ability 
The author is assuredly master of his art. His has of communicating his precise ideas in a style remark- 
been a life of observation and study, and in this work able for its clearness and simplicity." — IY , Journal 
he has given us the matured results of these mental of Medicine and Surgery, 
efforts."— New Orleans Medical Journal. "~" 



LEA & BLANCHARD'S PUBLICATIONS. 



WATSON'S PRACTICE— 



Continue (L 



Philadelphia, September 21th, 1844. 

Watson's Practice of Physic, in my opinion, is among the most com- 
prehensive works on the subject extant, replete with curious and important 
matter, and written with great perspicuity and felicity of manner. As 
calculated to do much good, I cordially recommend it to that portion of 
the profession in this country who may be influenced by my judgment. 

N. CHAPMAN, M.D. 



" We know not, indeed, of any work of the same 
size that contains a greater amount of interesting: and 
useful matter The author is evidently well acquainted 
with everything appertaining to the principles and 
practice of medicine, and has incorporated the stores 
of his well stocked mind, in the work before us, so 
ably and agreeably, that it is impossible for the inte- 



Professor of the Practice and Theory of Medicine 
in the University of Pennsylvania. 
" We are free to state that a careful examination of 
this volume has satisfied us that it merits all the com- 
mendation bestowed on it in this country and at 
home. It is a work adapted to the wants of young 
practitioners, combining, as it does, sound princip es 
and substantial practice. It is not too much to say 
that it is a representative of the actual state of medi- 



rest of the reader to flag for a moment. That they are cine as taught and practised by the most eminent phy- 

well adapted for such a purpose all must admit; but sicians of the present day, and as such we would 

their sphere of usefulness may extend much beyond advise every one about embarking in the practice of 

this. We are satisfied, indeed, that no physician, well physic to provide himself with a copy of it." — Western 

read and observant as he may be, can rise from their Journal of Medicine and Surgery. 

perusal without having added largely to his stock of "It is the production of a physician of undoubted 

valuable information." — Medical Examiner. talent and great learning, and whose industry in per- 



"The medical literature of this country has been 
enriched by a work of standard excellence, which we 
can proudly hold up to our brethren of other countries 
as a representative of the natural state of British me- 
dicine, as professed and practised by our most en- 
lightened physicians. And, for our own parts, we are 
not only willing that our characters as scientific phy- 
sicians and skilful practitioners may be deduced irom 



forming the most laborious duties of this profession 
has been well known for a long series of years. * * 
Let us not forget to add that the style and general 
character of the work are peculiarly practical ; and 
the cases which Dr. Watson has from time to time 
introduced to illustrate his views, are highly appro- 
priate and interesting, and add much to the value of 
the work; and this certainly must be admitted to be 



the doctrines contained in this book, but we hesitate one of the great advantages of casting this work in 

not to declare our belief that for sound, trustworthy the shape ot lectures, in which these cases assuredly 

principles, and substantial good practice, it cannot be appear more fitly, and in which they are introduced 

paralleled by any similar production in any other more easily and naturally than they could have been 

country. * * * * We w r ould advise no one to set had the form of the work been different. Lastly, we 

himself down in practice unprovided with a copy." — are well pleased to observe that a strong vein of 

British and Foreign Medical Revieiv. common sense, as well as good taste, runs through 

"We cannot refrain from calling the attention of the whole treatise, and sustains both the interest and 

our younger brethren, as soon as possible, to Dr. Wat- the confidence of the reader throughout." — Edinburgh 

son's Lectures, if they want a safe and comprehensive Medical and Surgical Journal. 

guide to the study of practical medicine. "In calling the attention of the profession Jo the ele- 



" In fact, to any of our more advanced brethren who 
wish to possess a commodious book of reference on 
any of the topics usually treated of in a course of lec- 



gant volume recently published by r Lea & Blanchard 
— the lectures delivered at King's College, London, by 
Dr. Watson — we do not suppose any one at all con- 



tures on the practice of physic, or who wish to have versant with the medical literature of the day to be 

a simple enunciation of any facts or doctrines which, unacquainted with its general character. Dr. VV. de- 

from their novelty or their difficulty, the busy practi- livered these now celebrated lectures during the me- 

tioner may not have made himself master of amidst dical session of 1S36-7. They have been revised by 

the all-absorbing toils of his professional career, we the author, and those who now study these erudite 

can recommend these lectures most cordially. Here productions will have them divested of any objection- 

we meet with none of those brilliant theories which able matter that might have formerly crept in through 

are so seductive to young men. because they are made inadvertence. There are ninety lectures, fully written, 

to explain every phenomenon, and save all the trouble embracing the whole domain of human maladies, with 

of observation and reflection; here are no exclusive their treatment, besides an appendix particularly re- 



doctrines; none of those 

'Bubbles that glitter as they rise and break 
On vain Philosophy's all babbling spring.' 
But we have the sterling production of a liberal, well- 
stored and truly honest mind, possessed of all that is 
currently known and established of professional know- 
ledge, and capable of pronouncing a trustworthy and 
impartial judgment on those numerous points in which 
Truth is yet obscured with false facts or false hypo- 
theses." — Provincial Medical Journal. 



markable for its richness in important practical infor- 
mation. We could not give even a tolerable synopsis 
of the subjects discussed in this great undertaking 
without materially entrenching on the limits assigned 
to other matter. * * * Open this huge, well-finished 
volume wherever we may r , the eye immediately rests 
on something that carries value on its front. VVe are 
impressed at once with the strength and depih of the 
lecturer'^ views: he gains on our admiration in pro- 
portion to the extent of our acquaintance with his 
profound researches. Whoever owns this book will 



; The style is correct and pleasing, and the matter have an acknowledged treasure, if the combined wis- 
worthy the attention of all practitioners, young and dom of the highest authorities is appreciated."— Boston 
old." — Western Lancet. Medical and Surgical Journal. 



HORNER'S _ANATOM¥. 
SPECIAL ANATOMY AND HISTOLOGY. 

BY WILLIAM E. HORNER, M.D., 

Professor of Anatpmy in the University of Pennsylvania, Member of the Imperial Medico-Chirurgical Academy 
of St. Petersburg, of the Am. Philosophical Society, &c, &c. 
Sixth Edition, in two Volumes, 8vo. 
"Another edition of this standard work of Professor Horner has made its appearance to which 
many additions have been made, and upon which much labour has been bestowed by the author. — 
The additions are chiefly in the department of Histology, or Elementary Anatomy, and so import- 
ant are they that the Professor has added the term to the title of his work. Every part of this 
edition eeems to have undergone the most careful revision, and its readers may rest assured of hav- 
ing the science of Anatomy fully brought up to the present day." — Am. Med. Journal. 



A M&®H%EWEE$T JUOT CH^AP WORE. 

SMITH & HORMER'S ANATOMICAL ATLAS, 

Just Published, Price Five Dollars in Parts. 



AN 

ANATOMICAL ATLAS 
ILLUSTRATIVE OF THE OTUGTUHE OF THE HUMAN BODY. 

BY HENRY H. SMITH, M.D., 

Fellow of the College of Physicians, $c. 
UNDER THE SUPERVISION OF 

WILLIAM E. HORNER, M.D., 

Professor of Anatomy in the University of Pennsylvania. 

In One large Volume, Imperial Octavo. 

This work is but just completed, having been delayed over the time intended by the great difficulty in giving 
to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows; 

Part I. The Bones and Ligaments, with one hundred and thirty engravings. 

Part II. The Muscular and Dermoid Systems, with ninety-one engravings. 

Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. 

Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. 

Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. 
Forming altogether a complete System of Anatomical Plates, of nearly 

SIX HUNDRED AND FIFTY FIGURES, 
executed in the best style of art, and making one iarge imperial octavo volume. Those who do not want it in 
parts ■can have the work bound in extra cloth or sheep at an extra cost. 

This work possesses novelty both in the design and the e xecution. It is the first attempt to apply engraving 
on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the 
publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of the 
work is at once novel and convenient. Each page is perfect in itself, the references being immediately under 
the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference 
backwards and forwards. The cuts are selected from the best and most accurate sources ; and, where neces- 
sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- 
sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- 
gation of the minute structure of the tissues. 

In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they 
now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific 
and artistieal point of view, while, at the same time, its-very low price places it within the reach of all. 

It is particularly adapted to supply the place of skeletons or subjects, as the profession will see by examining the list 
of plates now annexed. 



"These figures are well selected, and present a complete and accurate representation of that wonderful fabric, 
the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its 
superb artistieal execution, have been already pointed out. We must congratulate the student upon the 
completion of this atlas, as it is the most convenient work of the kind that has yet appeared ; and, we must 
add. the very beautiful manner in which it is ' got up' is so creditable to the country as to be flattering to our 
national pride." — American Medical Journal. 

"This is an exquisite volume, and a beautiful specimen of art. "We have numerous Anatomical Atlases, 
but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We 
strongly recommend to our friends, both urban and suburban, the purchase of this excellent work, for which 
both editor and publisher deserve the thanks of the profession." — Medical Examiner. 

"We would strongly recommend it, not only to the student, but also to the working practitioner, who, 
although grown rusty in the toils of his harness, still has the desire, and often the necessity, of refreshing his 
knowledge in this fundamental part of the science of medicine." — New York Journal of Medicine and Surg. 

" The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published m 
this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be 
conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy 
means of recalling the details learned in the dissecting room, and which are soon forgotten." — American Medi- 
cal Journal. 

" It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, 
surgeons and medical students." — Boston Med. and Surg. Journal. 

" It has been the aim of the author of the Atlas to comprise in it tne valuable points of all previous works, to 
embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate 
price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other field 
of practice." — Western Journal of Med. and Surgery. 

" These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the 
earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, 
and cordially recommend the work to ail engaged in die study of anatomy." — New York Journal of Medicine 
and Surgery. 

" A more elegant work than the one before us could not easily be placed by a physician upon the table of 
his student." — Western Journal of Medicine and Surgery. 

"We were much pleased with Part I, but the Second Part gratifies us still more, both as regards the attract- 
ive nature of the subject, (The Dermoid and Muscular Systems,) and the beautiful artistitfal execution of the 
Jlustrations. We have here delineated the most accurate microscopic views of some of the tissues, as, for 
instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and 
perspiralory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then 
follows ihe general anatomy of the muscles, and, lastly, their separate delineations. We would recommend 
this Anatomical Atlas to our readers in the very strongest terms."— New York Journal of Medicine and Sw 
gery. 



LIST OF 

THE ILLUSTRATIONS 

EMBRACING 

SIX HUNDRED AND THIRTY-SIX FIGURES 

IN SMITH AND HORNER'S ATLAS. 



A Highly-finished View of the Bones of the Head, 
View of Cuvier's Anatomical Theatre, . . . 



facing the title-page 
.... vignette 



PART I.— BONES 

Fig. 

1 Front view of adult skeleton. 

2 Back view of adult skeleton. 
S Foetal skeleton. 

4 Cellular structure of femur. 

5 Cellular and compound structure of tibia. 

6 Fibres of compact matter of bone. 

7 Concentric lamella of bone. 

8 Compact matter under the microscope. 

9 Haversian canals and lacuna of bone. 

10 Vessels of compact matter. 

11 Minute structure of bones. 

12 Ossification in cartilage. 

13 Ossification in the scapula. 

14 Puncta ossificationis in femur. 

15 Side view of the spinal column. 

16 Epiphyses and diaphysis of bone. 

17 External periosteum. 

18 Punctum ossificationis in the head. 

19 A cervical vertebra. 

20 The atlas. 21 The dentata. 

22 Side view of the cervical vertebrae. 

23 Side view of the dorsal vertebrae. 

24 A dorsal vertebra. 

25 Side view of the lumbar vertebrae. 

26 Side view of one of the lumbar vertebrae. 

27 Perpendicular view of the lumbar vertebrae. 

28 Anterior view of sacrum. 

29 Posterior view of sacrum. 

30 The bones of the coccyx. 

31 Outside view of the innominatum. 

32 Inside view of the innominatum. 

33 Anterior view of the male pelvis. 

34 Anterior view of the female pelvis. 

35 Front of the thorax. 36 The first rib. 

37 General characters of a rib. 

38 Front view of the sternum. 

39 Head of a Peruvian Indian. 

40 Head of a Choctaw Indian. 

41 Front view of the os frontis. 

42 Under surface of the os frontis. 

43 Internal surface of the os frontis. 

44 External surface of the parietal bone.s 

45 Internal surface of the parietal bone. 

46 External surface of the os occipitis. 

47 Internal surface of the os occipitis. 

48 External surface of the temporal bone. 

49 Internal surface of the temporal bone. 

50 Internal surface of the spheuoid bone. 

51 Anterior surface of the sphenoid bone. 

52 Posterior surface of the ethmoid bone. 

53 Front view of the bones of the face. 

54 Outside of the upper maxilla. 

55 Inside of the upper maxilla. 

56 Posterior surface of the palate bone. 

57 The nasal bones. 

58 The os unguis. 59 Inferior spongy bone. 
6b Right malar bone. 61 The vomer. 

62 Inferior maxillary bone. 

63 Sutures of the vault of the cranium. 



AND LIGAMENTS. 

Fig. 

64 Sutures of the posterior of the cranium. 

65 Diploe of the cranium. 

66 Inside of the base of the cranium. 

67 Outside of the base of the cranium. 

68 The facial angle. 69 The fontanels. 

70 The os hvoides. 

71 Posterior of the scapula. 

72 Axillary margin of the scapula. 

73 The clavicle. 74 The humerus. 
75 The ulna. 76 The radius. 

77 The bones of the carpus. 

78 The bones of the hand. 

79 Articulation of the carpal bones. 

80 Anterior view of the femur. 

81 Posterior view of the femur. 

82 The tibia. 83 The fibula. 

84 Anterior view of the patella. 

85 Posterior view of the patella. 

86 Theoscalcis. 87 The astragalus. 

88 The naviculare. 89 The cuboid bone. 

90 The three cuneiform bones. 

91 Top of the foot. 

92 The sole of the foot. 93 Cells in cartilage. 

94 Articular cartilage under the microscope. 

95 Costal cartilage under the microscope. 

96 Magnified section of cartilage. 

97 Magnified view of fibro-cartilage. 

98 White fibrous tissue. 

99 Yellow fibrous tissue. 

100 Ligaments of the jaw. 

101 Internal view of the same. 

102 Vertical section of the same. 

103 Anterior vertebral ligaments. 

104 Posterior vertebral ligaments. 

105 Yellow ligaments. 

106 Costo-vertebral ligaments. 

107 Occipito-altoidien ligaments. 

108 Posterior view of the same. 

109 Upper part of the same. 

110 Moderator ligaments. 

111 Anterior pelvic ligaments. 

112 Posterior pelvic ligaments. 

113 Sterno-clavicular ligaments. 

114 Scapulo-humeral articulation. 

115 External view of elbow joint. 

116 Internal view of elbow joint. 

117 Ligamentsof the wrist. 

118 Diagram of the carpal synovial membrane 

119 Ligaments of the hip joint. 

120 Anterior view of the knee joint. 

121 Posterior view of the knee joint. 

122 Section of the right knee joint. 

123 Section of the left knee joint. 

124 Internal side of the ankle joint. 

125 External side of the ankle joint. 

126 Posterior view of the ankle joint. 

127 Ligaments of the sole of the foot. 

128 Vertical section of the foot. 



PART II.— DERMOID AND MUSCULAR SYSTEMS. 



129 Muscles on the front of the body,/?/// length. 
131 Muscles on the back of the body, full length. 

130 The cellular tissue. 132 Fat vesicles. 



133 Blood-vessels of fat. 

134 Cell membrane of fat vesicles. 

135 Magnified view of the epidermis. 



Illustrations to Smith and Horner's %/2llas f continued. 



Fig. 

136 Cellular tissue of the skin. 

137 Kete mucosum, &c, of foot. 
1-38 Epidermis and rete mucosum. 

139 Cutis vera, magnified. 

140 Cutaneous papillae. 

141 Internal face of cutis vera. 

142 Integuments of foot under (he microscope. 



Fig. 

180 Side view of abdominal muscles. 

181 External parts concerned in hernia. 

182 Internal parts concerned in hernia. 

183 Deep-seated muscles of trunk. 

184 Inguinal and femoral rings. 

185 Deep-seated muscles of neck. 

186 Superficial muscles of back. 



143 Cutaneous glands. 144 Sudoriferous organs. 187 Posterior parietes of chest and abdomen. 



145 Sebaceous glands and hairs. 

146 Perspiratory gland magnified. 

147 A hair under the microscope. 

148 A hair from the face under the microscope. 

149 Follicle of a hair. 150 Arteries of a hair. 

151 Skin of the beard magnified. 

152 External surface of the thumb nail. 

153 Internal surface of the thumb nail. 

154 Section of nail of fore finger. 

155 Same highly magnified. 

156 Development of muscular fibre. 

157 Another view of the same. 

158 Arrangement of fibres of muscle. 

159 Discs of muscular fibre. 

160 Muscular fibre broken transversely. 

161 Striped elementary fibres magnified. 

162 Striae of fibres from the heart of an ox. 

163 Transverse section of biceps muscle. 

164 Fibres of the pectoralis major. 

165 Attachment of tendon to muscle. 

166 Nerve terminating in muscle. 

1 67 Superficial muscles of face and neck. 

3 68 Deep-seated muscles of face and neck. 

169 Lateral view of the same. 

170 Lateral view of superficial muscles of face. 

171 Lateral view of deep-seated muscles of face. 

172 Tensor tarsi or muscle of Horner. 

173 Pterygoid muscles. 174 Muscles of neck. 

175 Muscles of tongue. 

176 Fascia profunda colli, 

177 Superficial muscles of thorax. 

178 Deep-seated muscles of thorax. 



188 Under side of diaphragm. 

189 Second layer of muscles of back. 

190 Muscles of vertebral gutter. 

191 Fourth layer of muscles of back. 

192 Muscles behind cervical vertebrae. 

193 Deltoid muscle. 

194 Anterior view of muscles of shoulder. 

195 Posterior view of muscles of shoulder. 

196 Another view of the same. 

197 Fascia brachialis. 

198 Fascia of the fore-arm. 

199 Muscles on the back of the hand. 

200 Muscles on the front of the arm. 

201 Muscles on the back of the arm. 

202 Pronators of the fore-arm. 

203 Flexor muscles of fore-arm. 

204 Muscles in palm of hand. 

205 Deep flexors of the fingers. 

206 Superficial extensors. 

207 Deep-seated extensors. 

208 Rotator muscles of the thigh. 
309 Muscles on the back of the hip. 

210 Deep muscles on the front of thigh. 

211 Superficial muscles on the front of thigh. 

212 Muscles on the back of the thigh. 

213 Muscles on front of leg. 

214 Muscles on back of leg. 

215 Deep-seated muscles on back of leg. 

216 Muscles on the sole of the foot 

217 Another view of the same. 

218 Deep muscles on front of arm. 

219 Deep muscles on back of arm. 



179 Front view of abdominal muscles. 

PART III.— ORGANS OF DIGESTION AND GENERATION, 



220 Digestive organs in their whole length. 

221 Cavity of the mouth. 

222 Labial and buccal glands. 

223 Teeth in the upper and lower jaws. 

224 Upper jaw, with sockets for teeth. 

225 Lower jaw, with sockets for teeth. 

226 Under side of the teeth in the upper jaw. 

227 Upper side of the teeth in the lower jaw. 

228 to 235. Eight teeth, from the upper jaw. 
236 to 243. Eight teeth from the lower jaw. 
244 to 251. Side view of eight upper jaw teeth. 
252 to 259. Side view of eight lower jaw teeth. 
260 to 265. Sections of eight teeth. 

266 to 267. Enamel and structure of two of the 
teeth. 

268 Bicuspis tooth under the microscope. 

269 Position of enamel fibres. 

270 Hexagonal enamel fibres. 

271 Enamel fibres very highly magnified. 

272 A very highly magnified view of fig. 268. 

273 Internal portion of the dental tubes. 

274 External portion of the dental tubes. 

275 Section of the crown of a tooth. 

276 Tubes at the root of a bicuspis. 

277 Upper surface of the tongue. 

278 Under surface of the tongue. 

279 Periglottis turned off the tongue. 

280 Muscles of the tongue. 

281 Another view of the same. 

282 Section of the tongue. 

283 Styloid muscles, he. 

284 Section of a gustatory papilla. 

285 View of another papilla. 

286 Root of the mouth and soft palate. 

287 Front view of the pharynx and muscles. 



288 Back view of the pharynx and muscles. 

289 Under side of the soft palate. 

290 A lobule of the parotid gland. 

291 Salivary glands. 

292 Internal surface of the pharynx. 

293 External surface of the pharynx. 

294 Vertical section of the pharynx. 

295 Muscular coat of the oesophagus. 

296 Longitudinal section of the cesophagus. 

297 Parietes of the abdomen. 

298 Reflexions of the peritoneum. 

299 Viscera of the chest and abdomen. 

300 Another view of the same. 

301 The intestines in situ. 
S02 Stomach and ojsophagus. 

303 Front view of the stomach. 

304 Interior of the stomach. 

505 The stomach and duodenum. 

506 Interior of the duodenum. 

507 Gastric glands. 

308 Mucous coat of the stomach. 

309 An intestinal villus. 310 Its vessels. 

311 Glands of the stomach magnified. 

312 Villus and lacteal. 

313 Muscular coat of the ileum. 

314 Jejunum distended and dried. 

315 Follicles of Lieberkuhn 

316 Glands of Brunner. 317 Intestinal glands. 
318 Valvulce conniventes. 319 Ileo-colic valve. 

320 Villi and intestinal follicles. 

321 Veins of the ileum. 

322 Villi filled with chyle. 323 Peyer's glands 

324 Villi of the jejunum under the microscope. 

325 The caecum. 326 The mesocolon and colon, 
327 Muscular coat of the colon. 



Illustrations to Smith and Horner's Jltlas continued. 



Fig. 

328 Muscular fibres of the rectum. 

329 Curvatures of the large intestine. 

330 Mucous follicles of the rectum. 

331 Rectal pouches. 

332 Follicles of the colon, highly magnified. 

333 Folds and follicles of the stomach. 

334 Follicles, &c. of the jejunum. 
S35 Villi and follicles of the ileum. 
336 Muciparous glands of the stomach. 
S37 Ileum inverted, &c. 

338 Glands of Peyer magnified. 

339 Peritoneum of the liver injected. 

540 Liver in situ. 

541 Under surface of the liver. 342 Hepatic vein. 

343 Parenchyma of the liver. 

344 Hepatic blood-vessels. 345 Biliary ducts. 
S46 Angular lobules of the liver. 
347 Rounded hepatic lobules. 

548 Coats of the gall bladder. 

549 Gall bladder injected. 

550 Vena portarum. 
351 External face of the spleen. 

552 Internal face of the spleen. 

553 Splenic vein. 
354 Pancreas &c, injected. 355 Urinary organs. S97 Another view of the same 



Fig. 

373 Sphincter apparatus of the bladder. 

374 Prostate and vesicular seminales. 

375 Side view of the pelvic viscera. 

376 The glans penis injected. 

377 The penis distended and dried. 

378 Section of the same. 

379 Vertical section of the male pelvis, &c. 

380 Septum pectiniforme. 

381 Arteries of the penis. 

382 Vertical section of the urethra. 

383 Vesiculse seminales injected. 

384 Muscles of the male perineum. 

385 Interior of the pelvis, seen from above. 

386 Testis in the foetus. 

387 Diagram of the descent of the testis. 

388 Tunica vaginalis testis. 
S89 Transverse section of the testis. 

390 Relative position of the prostate. 

391 Vas deferens. 

392 Vertical section of the bladder. 

393 The testicle injected with mercury. 

394 Another view. 

395 Minute structure of the testis. 

396 Female generative organs. 



356 Right kidney and capsule. 

S57 Left kidney and capsule. 

358 Kidney under the microscope. 

S59 The ureter. 360 Section of right kidney. 

561 Section of the left kidney. 

562 Pyramids of Malpighi. 
363 Lobes of the kidney. 

S64 Renal arteries, &c, injected. 

365 Section of the kidney highly magnified. 

366 Copora Malpighiana. 367 Same magnified. 
368 Tubuli uriniferi. 369 Corpora Wolffiana. 

570 The bladder and urethra, full length. 

571 Muscular coat of the bladder. 



398 External organs in the foetus. 

399 Muscles of the female perineum. 

400 Side view of the female pelvis, &c. 

401 Relative position of the female organs. " 

402 Section of the uterus, &c. 

403 Fallopian tubes, ovaries, &c. 

404 Front view of the mammary gland. 

405 The same after removal of the skin. 

406 Side view of the breast. 

407 Origin of lactiferous ducts. 

408 Lactiferous tubes during lactation. 

409 Minute termination of a tube. 

410 Ducts injected ; after Sir Astley Cooper. 



372 Another view of the same. 

PART IV.— ORGANS OF RESPIRATION AND CIRCULATION, 



411 Front view of the thyroid cartilage. 

412 Side view of the thyroid cartilage. 

413 Posterior of the arytenoid cartilage. 

414 Anterior of the arytenoid cartilage. 

415 Epiglottis cartilage. 416 Cricoid cartilage. 

417 Ligaments of the larynx. 

418 Side view of the same. 

419 The thyroid gland. 

420 Internal surface of the larynx. 

421 Crico-thyroid muscles. 

422 Crico-arytenoid muscles. 

423 Articulations of the larynx. 

424 Vertical section of the larynx. 

425 The vocal ligaments. 426 Thymus gland. 

427 Front view of the lungs. 

428 Back view of the lungs. 

429 The trachea and bronchia. 

430 Lungs, heart, &c. 

431 First appearance of the blood-vessels. 

432 Capillary vessels magnified. 

433 Another view of the same. 

434 Blood globules. 

435 Another view of the same. 

436 The mediastina. 

437 Parenchyma of the lung. 

438 The heart and pericardium. 

439 Anterior view of the heart. 

440 Posterior view of the heart. 

441 Anterior view of its muscular structure. 

442 Posterior view of the same. 

443 Interior of the right ventricle. 

444 Interior of the left ventricle. 

445 Mitral valve, the size of life. 

446 The auriculo-ventricular valves. 

447 Section of the ventricles. 

448 The arteries from the arch of the aorta. 

449 The arteries of the neck, the size of life. 



450 The external carotid artery. 

451 A front view of arteries of head and neck. 

452 The internal maxillary artery. 

453 Vertebral and carotid arteries with the aorta. 

454 Axillary and brachial arteries. 

455 The brachial artery. 

456 Its division at the elbow. 

457 One of the anomalies of the brachial artery. 

458 Radial and ulnar arteries. 

459 Another view of the same. 

460 The arcus sublimis and profundus. 

461 The aorta in its entire length. 

462 Arteries of the stomach and liver. 

463 Superior mesenteric artery. 

464 Inferior mesenteric artery. 

465 Abdominal aorta. 

466 Primitive iliac and femoral arteries. 

467 Perineal arteries of the male. 

468 Position of the arteries in the inguinal canal. 

469 Internal iliac artery. 470 Femoral artery. 

471 Gluteal and ischiatic arteries. 

472 Branches of the ischiatic artery. 

473 Popliteal artery. 

474 Anterior tibial artery. 

475 Posterior tibial artery. 

476 Superficial arteries on the top of the foot. 

477 Deep-seated arteries on the top of the foot. 

478 Posterior tibial artery at the ankle. 

479 The plantar arteries. 

480 Arteries and veins of the face and neck. 

481 Great vessels from the heart. 

482 External jugular vein. 

483 Lateral view of the vertebral sinuses. 

484 Posterior view of the vertebral sinuses. 

485 Anterior view of the vertebral sinuses. 

486 Superficial veins of the arm. 

487 The same at the elbow. 



Illustrations to Smith and Horner's Atlas continued. 



488 The veins of the hand. 

489 The great veins of the trunk. 

490 Positionsofthearteriesand veinsofthe trunk. 

491 The vense cavas. 492 The vena portarum. 

493 Deep veins of the hack of the leg. 

494 Positions of the veins to the arteries in the 

arm. 495 Superficial veins of the thigh. 

496 Saphena vein. 

497 Superficial veins of the leg. 

498 Lymphatics of the upper extremity. 



Fig. 

499 The lymphatics and glands of the ax-lla. 

500 The femoral and aortic lymphatics. 

501 The lymphatics of the small intestines. 

502 The thoracic duct. 

503 The lymphatics of the groin. 

504 Superficial lymphatics of the oigh. 

505 Lymphatics of the jejunum. 

506 Deep lymphatics of the thigh. 

507 Superficial lymphatics of the leg. 

508 Deep lymphatics of the leg. 



PART V.— THE NERVOUS SYSTEM AND SENSES. 



509 
510 
511 

512 
513 

514 
515 
516 
517 
518 
519 
520 
521 
522 
523 
524 
525 
526 
527 
528 
529 
530 
531 
532 
533 
534 
535 
536 
537 
538 
539 
540 
541 
542 
543 
544 
545 
546 
547 
548 
549 
550 
551 
552 
553 
554 
555 
556 
557 
559 
560 
561 
562 
563 
564 
565 
566 
567 
568 
569 
570 
571 



Dura mater cerebri and spinalis. 573 

Anterior view of brain and spinal marrow. 574 

Anterior view of the spinal marrow, &c. 575 

Lateral view of the spinal marrow, &c. % 576 

Posterior view of the spinal marrow, &c. 577 

Decussation of Mitischelli. 578 

Origins of the spinal nerves. 579 
Anterior view of spinal marrow and nerves. 580 
Posterior view of spinal marrow and nerves. 581 

Anterior spinal commissure. 582 

Posterior spinal commissure. 583 

Transverse section of the spinal marrow. 584 

Dura mater and sinuses. 585 

Sinuses laid open. 586 

Sinuses at the base of the cranium. 587 

Pons Varolii, cerebellum, &c. 588 

Superior face of the cerebellum. 589 

Inferior lace of the cerebellum. 590 

Another view of the cerebellum. 591 

View of the arbor vitse, &c. 593 

Posterior view of the medulla oblongata. 594 

A vertical section of the cerebellum. 595 

Another section of the cerebellum. 596 

Convolutions of the cerebrum. 597 

The cerebrum entire. 598 

A section of its base. 599 

The corpus callosum entire. 600 

Diverging fibres of the cerebrum, &c. 601 

Vertical section of the head. 602 

Section of the corpus callosum. 603 

Longitudinal section of the brain. 604 

View of a dissection by Gall. 605 

The commissures of the brain. 606 

Lateral ventricles. 607 

Corpora striata-fornix, &c. 608 

Fifth ventricle and lyra. 609 

Anotherj)view of the lateral ventricles. 610 

Another view of the ventricles. 611 

Origins of the 4th and 5th pairs of nerves. 612 

The circle of Willis. 613 

A side view of the nose. 614 

The nasal cartilages. 615 

Bones arid cartilages of the nose. 616 

Oval cartilages, kc. 617 

Schneiderian membrane. 618 

External parietes of the left nostril. 619 

Arteries of the nose. 620 

Pituitary membrane injected. 621 
Posterior jyv«s. 558 Front view of the eye. 622 

Side view of the eye. 623 

Posterior view of the eyelids, &c. 624 

Glandulaj palpebrarum. 625 

Lachrymal canals. 626 

Muscles of the eyeball. 627 

Side view of the eyeball. 628 

Longitudinal section of the eyeball. 629 

Horizontal section of the eyeball. 630 

Anterior view of a transverse section. 631 

Posterior view of a transverse section. 632 

Choroid coat injected. 633 

Veins of the choroid coat. 634 
The iris. 572 Thejretfia and lens. 



External view of the same. 

Vessels in the conjunctiva. 

Retina, injected and magnified. 

Iris, highly magnified. 

Vitreous humour and lens. 

Crystalline adult lens. 

Lens of the foetus, magnified. 

Side view of the lens. 

Membrana pupillaris. 

Another view of the same. 

Posterior view of the same. 

A view of the left ear. 

Its sebaceous follicles. 

Cartilages of the ear. 

The same with its muscles. 

The cranial side of the ear. 

Meatus auditorius externus, &c. 

Labyrinth and bones of the ear. 

Full view of the malleus. 592 The incus. 

Another view of the malleus. 

A front view of the stapes. 

Magnified view of the stapes. 

Magnified view of the incus. 

Cellular structure of the malleus. 

Magnified view of the labyrinth. 

Natural size of the labyrinth. 

Labyrinth laid open and magnified. 

Labyrinth, natural size. 

Labyrinth of a foetus. 

Another view of the same. 

Nerves of the labyrinth. 

A view of the vestibule, &c. 

Its soft parts, &c. 

An ampulla and nerve. 

Plan of the cochlea. 

Lamina spiralis, &c. 

The auditory nerve. 

Nerve on the lamina spiralis. 

Arrangement of the cochlea. 

Veins of the cochlea, highly magnified. 

Opening of the Eustachian tube in the throat 

Portio mollis of the seventh pair of nerves 

The olfactory nerves. 

The optic and seven other pairs of nerves. 

Third, fourth and sixth pairs of nerves. 

Distribution of the fifth pair. 

The facial nerve. 

The hypo-glossal nerves. 

A plan of the eighth pair of nerves. 

The distribution of the eighth pair. 

The great sympathetic nerve. 

The brachial plexus. 

Nerves of the front of the arm. 

Nerves of the back of the arm. 

•Lumbar and ischiatic nerves. 

Posterior branches to the hip, &c. 

Anterior crural nerve. 

Anterior tibial nerve. 

Branches of the popliteal nerve. 

Posterior tibial nerve on the leg. 

Posterior tibial nerve on the (cat 



LEA & BLANCHARD'S PUBLICATIONS. 15 

ftfSFESSOl DOISLISOM^S WORKS. 

The Works of Professor Dunglison on various departments of Medicine are here presented. — 
Nearly all of them are extensively used as text books in the branches of science to which they re- 
late, and the profession and students may rely upon the great care and accuracy of the author in 
having each new edition of his works posted up to the day of publication. 

A NEW EDITION OF THE STANDARD MEDICAL DICTIONARY. 

A DICTIONARY OF~F$EDSCAL SCIENCE; 

CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS, WITH 
THE FRENCH AND OTHER SYNONYMES, NOTICES OF CLIMATES AND OF CELE- 
BRATED MINERAL WATERS, FORMULAE FOR VARIOUS OFFICINAL AND EMPIRI- 
CAL PREPARATIONS, &c. 
Fifth Edition, Extensively Modified and Improved over former Editions. 
BY ROBLEY DUNGLISON, M.D. 
Professor of the Institutes of Medicine, &c, in Jefferson Medical College, Philada.; Secretary to 
the American Philosophical Society, &c, &c. 
In one large royal octavo volume of nearly SCO double columned pages, and bound with raised bands. 
The author's object has not been to make the work a mere Lexicon, or Dictionary of terms, but 
to afford, under each, a condensed view of its various medical relations, and thus to render the 
work a complete epitome of the existing condition of medical science. This he has been in a great 
measure enabled to do, as the work is not stereotyped, by adding in each successive edition all 
new and interesting matters or whatever of importance had been formerly omitted. To show 
the advantage of this, it need only be remarked that in the present work will be found at least two 
thousand subjects and terms not embraced in the third edition. 

" To execute such a work requires great erudition, unwearied industry, and extensive research ; 
and we know no one who could bring to the task higher qualifications of this description than Pro- 
fessor Dunglison." — American Medical Journal. 



DUNGLISON'S PRACTICE, A NEW EDITION. 

THIS PRACTICE OP Bf BBICENE, 
OR A TREATISE CM SPECIAL PATHOLOGY AMD THERAPEUTICS. 

BY ROBLEY DUNGLISON, M.D., 
Second Edition, carefully Revised and with Additions. 
In Two Large Octavo "Volumes of over thirteen hundred pages. 
The Publishers annex a condensed statement of the Contents: — Diseases of the Mouth, Tongue, 
Teeth, Gums, Velum Palati and Uvula, Pharynx and OZsophagus, Stomach, Intestines, Peritoneum, 
Morbid Productions in the Peritoneum, and Intestines. — Diseases of the Larynx and Trachea, Bron- 
chia and Lungs, Pleura, Asphyxia. — Morbid conditions of the Blood, Diseases of the Heart and 
Membranes, Arteries, Veins, Intermediate or Capillary Vessels, — Spleen, Thyroid Gland, Thymus 
Gland, and Supra Renal Capsules, Mesenteric Glands, — Salivary Glands, Pancreas, Biliary Appara- 
tus, Kidney, Ureter, Urinary Bladder. — Diseases of the Skin, Exanthematous, Vesicular, Bullar, 
Pustular, Papular, Squamous, Tuberculous, Macula?, Syphilides. — Organic Diseases of the Nervous 
Centres, Neuroses, Diseases of the Nerves. — Diseases of the Eye, Ear, Nose. — Diseases of the 
Male and Female Organs of Reproduction. Fever, — Intermittent, Remittent, Continued, Eruptive, 
Arthritic. — Cachexies, Scrofulous, Scorbutic, Chlorotic, Rhachitic, Hydropic and Cancerous. 

This work has been introduced as a text-bookin many of the Medical Colleges, 
and the general favour with which it has been received, is a guarantee of its value 
to the practitioner and student. 

" In the volumes before us, Dr. Dunglison has proved that his acquaintance with the present facts 
and doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, 
and impartiality with which the materials of the work have been collected, weighed, arranged, and 
exposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate 
the source of information, and under the head of treatment, formula? of the most appropriate reme- 
dies are everywhere introduced. We congratulate the students and junior practitioners of Ame- 
rica, on possessing in the present volumes, a work of standard merit, to which they may confidently 
refer in their doubts and difficulties." — British and Foreign Medical Revieiv, for July, 1842. 

" Since the foregoing observations were written, Ave have received a second edition of Dungli- 
son's work, a sufficient indication of the high character it has already attained in America, and 
justly attained." — British and Foreign Medical Review, for October, 1844. 

"We hail the appearance of this work, which has just been issued from the prolific press of 
Messrs. Lea & Blanchard of Philadelphia, with no ordinary degree of pleasure. Comprised in two 
large and closely printed volumes, it exhibits a more full, accurate, and comprehensive digest of 
the existing state of medicine than any other treatise with which we are acquainted in the English 
language. It discusses many topics — some of them of great practical importance, which are en- 
tirely omitted in the writings of Eberle, Dewees, Hosack, Graves, Stokes, Mcintosh, and Gregory ; 
and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, as 
it affords him ready access to information of which he stands in daily need in the exercise of his 
profession." — Louisvillt Journal. 



16 LEA & BLANCHARD'S PUBLICATIONS. 

PROFESSOR DIMGLISON'S WORKS— Continued. 

anaM. immvmmfkm materia medica, 

ADAPTED FOR A MEDICAL TEXT-BOOK. 

BY ROBLEY DUNGLISON, M.D., 

In two Volumes, 8vo. 

" The subject of Materia Medica has been handled by our author with more than usual judgment. 
The greater part of treatises on that subject are, in effect expositions of the natural and chemical 
history of the substances used in medicine, with very brief notices at all of the indications they are 
capable of fulfilling, and the general principles of Therapeutics. Dr. Dunglison, very wisely, in 
our opinion, has reversed all this, and given his principal attention to the articles of the Materia 

Medica as medicines In conclusion, we strongly recommend these volumes to our readers. — 

No medical student on either side of the Atlantic should be without them." — Forbes' British and 
Foreign Medical Review. 

" Our junior brethren in America will find in these volumes of Professor Dunglison a e Thesau- 
rus Medicaminum,' more valuable than a large purse of gold." — Medico-Chirurgical Review, for 
January, 1845. 

WITH UPWARDS OF THREE HUNDRED ILLUSTRATIONS, 
BY ROBLEY DUNGLISON, M.D., 

Fifth Edition, Greatly Modified and Improved, in 2 Vols, of 1304 Large Octavo Pages. 

" We have on two former occasions, brought this excellent work under the notice of our readers, 
and we have now only to say that, instead of falling behind in the rapid march of physiological 
science, each edition brings it nearer to the van. Without increasing the bulk of the treatise, the 
author has contrived to introduce a large quantity of new matter into this edition from the works of 
Valentin, Bischoff, Henle, Wildebrand, Muller, Wagner, Mandl, Gerber, Liebig, Carpenter, Todd 
and Bowman, as well as from various monographs which have appeared in the Cyclopaedias, Trans- 
actions of learned societies and journals. The large mass of references which it contains renders 
it a most valuable bibliographical record, and bears the highest testimony to the zeal and industry 
of the author." — British and Foreign Medical Review. 

" Many will be surprised to see a fifth edition of this admirable treatise so rapidly succeeding the 
fourth. But such has been the rapid progress of physiology within a short period that to make his 
work a fair reflection of the present state of the science, no less than an account of its extensive 
popularity, Dr. Dunglison has found it necessary to put forth a new edition with material modifica- 
tions and additions. To those who may be unacquainted with the work, we may say that, Dr. D. 
does not belong to the mechanical, chemical, or vital school exclusively ; but that, with a discri- 
minating hand he culls from each and all, making his treatise a very excellent and complete digest 
of the vast subject." — Western Journal of Medicine and Surgery. 



NEW REMEDIES, 
PHARMACEUTIGALLY AID THERAPEUTICALLY CONSIDERED, 

BY ROBLEY DUNGLISON, M.D., 
In One Volume, Octavo, over 600 pages, the Fourth Edition. 



Or, the Influence of Atmosphere and Localit)', Change of Air and Climate, 

Seasons, Food, Clothing, Bathing and Mineral Springs, Exercise, 

Sleep, Corporeal and Intellectual Pursuits, &c, &c, on 

Healthy Man : Constituting x 

ELEMENTSOF HYGIENE. 

BY ROBLEY DUNGLISON, M.D. 
A New Edition with many Modifications and Additions. In One Volume, Svo. 
"We have just received the new edition of this learned work on the ' Elements of Hygiene.' — 
Dr. Dunglison is one of the most industrious and voluminous authors of the day. How he finds 
time to amass and arrange the immense amount of matter contained in his various works, is almost 
above the comprehension of men possessing but ordinary talents and industry. Such labour de- 
serves immortality." — St. Louis Med. and Surg. Journal. 



A NEW EDITION OF 

THE MEDICAL STUDENT, 

OR AIDS TO THE STUDY OF MEDICINE. 

A REVISED AND MODIFIED EDITION. 

BY ROBLEY DUNGLISON, M.D., 

In One neat 12mo. Volume. 



LEA & BLANCHARD'S PUBLICATIONS. \7 

CHAPMAN'S WORKS ON THE PRACTICE OF MEDICINE. 
CHAPMAN ON FEVERS, ETC. 

LECTURES ON THE MORE IMPORTANT 

ERUPTIVE FEVERS, HEMORRHAGES AND 

DROPSIES, AND ON GOUT AND RHEUMATISM, 

DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 

By N. CHAPMAN, M.D., 

Professor of the Theory and Practice of Medicine, &c. &c. 

In one neat Octavo Volume. 
This volume contains Lectures on the following subjects : 

EX ANTHEM ATOUS FEVERS. 

Variola, or Small Pox ; Inoculated Small Pox; Varicella, or Chicken Pox ; Variolae Vaccinise, or Vaccinia, 
or Cow-pock; Varioloid Disease ; Rubeola, Morbilli, or Measles ; Scarlatina vel Febris Rubra— Scarlet Fever. 

HAEMORRHAGES. 

Haemoptysis, Spitting of Blood; Haemorrhagia Narium, or Haemorrhage from the Nose; Haematemesis, or 
Vomiting of Blood ; Haematuria, or Voiding of Bloody Urine ; Haemorrhagia Uterina, or Uterine Haemorrhage ; 
Haemorrhois or Haemorrhoids; Cutaneous Haemorrhage ; Purpura Haemorrhagica. 

DROPSIES. 

Ascites; Encysted Dropsy; Hydrothorax; Hydrops Pericardii; Hydrocephalus Internus, a&ute, subacute, 
and chronic : Anasarca; with a Disquisition on the Management of the whole. 

GOUT, RHEUMATISM, &c. &c. 

"The name of Chapman stands deservedly high in the annals of American medical science. A teacher and a 
lecturer for nearly forty years, in the oldest and, we believe, the first medical school on this side of the Atlantic, 
the intimate friend and companion of Rush, Kuhn, Physick, Wistar, Wooclhouse, Dewees, and a host of others 
scarcely less renowned, Professor Chapman reflects upon the profession of this generation something of the 
genius and wisdom of that which has passed; he stands out the able and eloquent champion of the doctrines 
and principles of other times, when Cullen's "first lines" formed the rule of faith for all the Doctors in Medicine 
throughout Christendom. In him is embodied the experience of three score and ten, strengthened by reading, 
and enlightened by a familiar intercourse with many of the ablest medical men in the New and Old World. 

" In conclusion, we must declare our belief that the name of Chapman will survive when that of many of his 
cotemporaries shall have been forgotten ; when other generations shall tread the great theatre of human 
affairs, and when other discoveries yet undisclosed, shall shed a brighter light upon the path of medical science. 
The various lectures which he has been publishing, containing, as they do, the doctrines that he has so long 
and so eloquently taught to large and admiring classes, we doubt not will be welcomed with delight by his nu- 
merous pupils throughout the Union." — New Orleans Medical Journal. 

CHAPMAN ON TH ORAC IC VISCERA, ETC. 

LECTURES ON THE MORE IMPORTANT DISEASES 

OF THE 

THORACIC AND ABDOMINAL VISCERA, 

DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
By N. CHAPMAN, M. D. 

Professor of the Theory and Practice of Medicine, &c. 

In one Volume, Octavo. 

WILLIAMS AND CLYMER O N THE RESPIRATORY ORGANS, ETG. 

A TREATISE ON THE 

DISEASES OF THE RESPIRATORY ORGANS, 

INCLUDING 

THE TRACHEA, LARYNX, LUNGS, AND PLEURA. 
By CHARLES J. B. WILLIAMS, M.D., 

Consulting Physician to the Hospital for Consumption and Diseases of the Chest; Author of 
" Principles of Medicine," &c. &c. 

WITH NUMEROUS ADDITIONS AND NOTES. 
By MEREDITH CLYMER, M.D., 

Physician to the Philadelphia Hospital. 

In one neat 8vo. Volume, with Cuts. 

This work recommends itself to the notice of the profession as containing a more particu- 
lar and detailed account of the affections of which it treats than perhaps any other volume 
before the public. 

" The wood cuts illustrating the physical examination of the chest, are admirably executed, and the whole 
mechanical execution of the work, does much credit to the publishers. This work is undoubtedly destined to 
take precedence of all others yet published on the " Respiratory Organs," and as a text book for teachers and 
students, no better in the present state of the science is to be expected."— -New York Journal of Medicine. 



18 LEA & BLANCHARD'S PUBLICATIONS. 

MOW READY, 

A NEW AND IMPROVED EDITION 

OF RAMSBBTEAM'S STANDABD WORK ON PARTURITION. 



THE PRINCIPLES AND PRACTICE OF 

QRSTETRIG MERIGINE AND SURGERYj 

IN REFERENCE TO 

THE PROCESS OF PARTURITION. 

ILLUSTRATED BY 

-One hundred and forty-eight Zsarge figures on 85 lithographic Plates. 
By FRANCIS H. RAMSBOTHAM, M. D., &c. 

A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. 

In one large imperial octavo volume, well bound. . 

The present edition of this standard work will be found to contain numerous and important improvements 
over the last. Besides much additional matter, there are several more plates and wood-cuts, and those which 
were before used have been re-drawn. This book has long been known to the profession, by whom it has 
■been most flatteringly received. The publishers take great pleasure in submitting the following testimony to 
ats value from Professor Hodge, of the Pennsylvania University. 

Philadelphia, August 6th, 1845. 
Gentlemen:— I have looked over the proofs of Ramsbotham on Human Parturition, with its important 
improvements, from the new London edition. 

This Work needs no commendation from me, receiving, as it does, the unanimous recommendation of the 
British periodical press, as the standard work on Midwifery ; " chaste in language, classical in composition, 
happy in pointof arrangement, and abounding in most interesting illustrations."* 

To the American public, therefore, it is most valuable— from its intrinsic undoubted excellence, and as 
being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive through- 
out our country. 

There is, however, a portion of Obstetric Science to which sufficient attention, it appears to me. has not 
been paid. Through you, I have promised to the public a work on this subject, and although the continued 
occupation of my time and thoughts in the duties of a teacher and practitioner have as yet prevented the ful- 
filment of the promise, the day, I trust, is not distant, when, under the hope of being useful, I shall prepare 
an account of the Mechanism of Labour, illustrated by suitable engravings, which may be regarded as an 
addendum to the standard works of Ramsbotham, and our own Dewees. 

Very respectfully, yours, 

HUGH L. HODGE, M. D., 
Professor of Obstetrics, Sfc. $c, in the University of Pennsylvania. 
Messrs. Lea & Blanchard. 



,: This new edition of Dr. Ramsbotham's work forms one of the most complete and thoroughly useful treatises 
on Midwifery with which we are acquainted. It is not a mere reprint of the first edition; the entire work 
has undergone a careful revision, with additions. We have already given specimens of the work sufficient 
to justify our hearty recommendation of it as one of the best guides that the student or young practitioner can 
follow." — British and Foreign Medical Review, Jan., 1845. 

11 The work of Dr. Ramsbotham may be described as a complete system of the principles and practice of 
Midwifery; and the author has been at very great pains, indeed, to present a just and useful view of the pre- 
sent state of obstetrical knowledge. The illustrations are numerous, well selected, and appropriate, and en- 
graved with great accuracy and ability. In short, we regard this work, between accurate descriptions and 
useful illustrations, as by far the most able work on the Principles and Practice of Midwifery that has ap- 
peared for a long time. Dr. Ramsbotham has contrived to infuse a larger proportion of common sense, and 
plain unpretending practical knowledge into this work, than is commonly found in works on this subject; 

* Northern Journal of Medicine for July 1845. 



LEA & BLANCHARD'S PUBLICATIONS. 19 

ZLAmSBQTKAm CBJ PAB-TUBITlOrJ—Continued. 

and as such we have great pleasure in recommending it to the attention of obstetrical practitioners." — Edin- 
burgh Medical and Surgical Journal. 

"This is one of the most beautiful works which have lately issued from the medical press; and is alike 
creditable to the talents of the author and the enterprise of the publisher. It is a good and thoroughly prac- 
tical treatise ; the different subjects are laid down in a clear and perspicuous form, and whatever is of import 
ance, is illustrated by first rate engravings. A remarkable feature of this work, which ought to be mentioned, 
is its extraordinary cheapness. As a work conveying good, sound, practical precepts, and clearly demonstra- 
ting the doctrines of Obstetrical Science, we can confidently recommend it either to the student or practi- 
tioner." — Edinburgh Journal of Medical Science. 

"This work forms a very handsome volume. Dr. Ramsbotham has treated the subject in a manner worthy 
of the reputation he possesses, and has succeeded in forming a book of reference for practitioners, and a solid 
and easy guide for students. Looking at the contents of the volume, and its remarkably low price, we have 
no hesitation in saying that it has no parallel in the history of publishing."— Provincial Medical and Surgi- 
cal Journal. 

"It is the book of Midwifery for students ; clear, but not too minute in its details, and sound in its practi- 
cal instructions. It i3 so completely illustrated by plates (admirably chosen and executed.) that the student 
must be stupid indeed who does not understand the details of this branch of the science, so far at least as 
description can make them intelligible." — Dublin Journal of Medical Science. 

"Our chief object now is to state our decided opinion, that this work is by far the best that has appeared in 
this country for those who seek practical information upon Midwifery, conveyed in a clear and concise style. 
The value of the work, too, is strongly enhanced by the numerous and beautiful drawings, which are in the 
first style of excellence."— London Medical Journal. 

"We most earnestly recommend this work to the student who wishes to acquire knowledge, and to the 
practitioner who wishes to refresh his memory, as a most faithful picture of practical Midwifery ; and we can 
with justice say, that altogether it is one of the best books we have read on the subject of Obstetric Medi- 
cine."— Medico-Chirurgical Review. 

"All the organs concerned in the process of parturition, and every step of this process, in all its different 

forms, are illustrated with admirable plates When we call to mind the toil we underwent in 

acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which thi3 

work will afford him We recommend the student who desires to master this difficult subject with 

the least possible trouble, to possess himself at once of a copy of this work." — American Journal of the Me- 
dical Sciences. 

"It is intended expressly for students and junior practitioners in Midwifery ; it is, therefore, as it ought to 
be, elementary, and will not consequently, admit of an elaborate and extended review. Our chief object, 
now is to state our decided opinion, that this work is by far the best that has appeared in this country, for 
those who seek practical information upon Midwifery, conveyed in a clear and concise style. The value of 
the work, too, is strongly enhanced by the numerous and beautiful drawings by Bagg, which are in the first 
style of excellence. Every point of practical importance is illustrated, that requires the aid of the engraver 
to fix it upon the mind, and to render it clear to the comprehension of the student."— London Medical 
Gazette. 

"We feel much pleasure in recommending to the notice of the profession one of the cheapest and most ele- 
gant productions of the medical press of the present day. The text is written in a clear, concise, and simple 
style. We offer our most sincere wishes that the undertaking may enjoy all the success which it so well 
merits."— Dublin Medical Press. 

"We strongly recommend the work of Dr. Ramsbotham to all our obstetrical readers, especially to those 
who are entering upon practice. It is not only one of the cheapest, but one of the most beautiful works in 
Midwifery."— British and Foreign Medical Review. 

" Among the many literary undertakings with which the Medical press at present teems, there are few that 
deserve a warmer recommendation at our hands than the work — we might almost say the obstetrical library, 
comprised in a single volume — which is now before us. Few works surpass Dr. Ramsbotham's in beauty and 
elegance of getting up, and in the abundant and excellent engravings with which it is illustrated. We hear- 
tily wish the volume the success which it merits, and we have no doubt that before long it will occupy a 
place in every medical library in the kingdom. The illustrations are admirable; they are the joint production 
of Bagg and Adlard, and comprise within the series the best obstetrical plates of our best obstetrical authors, 
ancient and modern. Many of the engravings are calculated to fix the eye as much by their excellence of 
execution, and their beauty as works of art, as by their fidelity to nature and anatomical accuracy." — The 
Lancet. 

" Thi3 is a work of unusual interest and importance to students and physicians. It is from the pen of Dr. 
Ramsbotham, consulting physician in obstetric cases of the London Hospital, and embodies in one volume 
the Principles and Practice of Obstetric Medicine and Surgery. The treatise is admirably written, and illus- 
trated by a great variety of engravings: Indeed everything in the obstetric art, capable of being explained 
by engravings, i3 displayed to the eye in these admirably executed prints. A medical correspondent of the 
New York American, says, that the 'universal voice of the British journals accords in commending this 
work to the profession, as one of the best elementary treatises in the language,' and we can only say, in addi- 
tion, that the American publishers have, as far as we can judge from the execution of the plates in their edi- 
tion, done full justice to the original work. We sincerely hope that it may meet with entire success, and we 
cannot doubt that, when its merits are fully known, it will befound in every medical library in the country-.*' 
— Saturday Evening Post. 



20 LEA & BLANCHARD'S PUBLICATIONS. 

Now Ready, 
CHEMISTRY FOR STUDENTS. 



ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. 

By GEORGE FOWNES, Ph. D., 

Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. 

With Numerous Illustrations. Edited, with Additions, 

By ROBERT BRIDGES, M. D., 

Professor of General and Pharmaceutical Chemistry in the Philadelphia College 
of Pharmacy, &c, &c. 

In one large duodecimo volume, sheep or extra cloth. 

This is among the cheapest volumes on Chemistry yet presented to the pro- 
fession. The character of the work is such as should recommend it to all col- 
leges in want of a text-book as an introduction to the larger and more advanced 
systems, such as Graham's and others. The great advantage which it possesses 
over all the other elementary works on the same subject now before the public, 
is the perfect manner in which it is brought up to the day on every point, em- 
bracing all the latest investigations and discoveries of importance, in a concise 
and simple manner, adapted to the time and comprehension of students com- 
mencing the science- It forms a royal 12mo. volume of 460 large pages, on small 
type, embellished with over one hundred and sixty wood engravings, which 
wiill fee found peculiarly instructive as to the practical operations of the labora- 
tory, and the new and improved methods of experimenting. 

It has already been adopted as a Text-book by Professor Silliman of Yale Col- 
siege, and by other Colleges in different parts of the country. 



■Extract from a. letter from Professor MillingtOH, of being omitted, and appears to us extremely well 

William ■and Mary College, Va. adapted as a text-book for the pupil attending a course 

of lectures on chemistry. Indeed we have no doubt 

"I have perused the book with much pleasure, and ^ h wi]1 ^timately become the medical student's 

find it a most admirable work; and, to my mind, such favourite man ual.»-D^/tn Medical Press. 

A oneas ie just now much needed in schools and col- „ Hay . examined u with sorae alten tion, we feel 

leges. * * * All the books I have met with on che- i ified t0 recommend itt0 our younger readers as an 

smstry-areeimer too puer.le^ too erud,te,and I con- admirable exposition of the preS ent state of chemical 

fess Dr. Fownes-book seems te be the .happiest medium n.,^ . dearly written, and displaying a 

I ha*e*een, and admirably suited to fill up the hiatus." thorough ^ knowledge of its details , as weU as 

, . a profound acquaintance with its principles." — British, 

and Foreign Medical Review. 

Extra* fromv letter from Professor W. E. A. Aikin, of u Numerous and useml as are the works ex tant on 

the University of Maryland. xh& Science of chemistry, we are nevertheless pre- 

« The first eursory examination left me prepossessed pared to admit that the author of this publication has 

in its fevour, and a subsequent more careful review made a valuable addition to them by offering the stu- 

has confirmed these firet impressions.- I shall certainly dent and those in general who desire to obtain in forma- 

recoremend it to my el&sses, and feel sure that they tion, an accurate compendium of the state of chemical 

will profit by using it during the session of lectures. science ; which is, moreover, well illustrated by ap- 

" As a judicious compendium, I think Fownes' Che- propriate and neatly executed wood engravings. * * 

mistry cannot fail to be highly useful to the class of After what we have stated of this work, our readers 

readers for whom it was designed." will not be surprised that it has our hearty commenda- 
tion, and that, in our opinion, it is calculated, and at a 
trifling expense, to spread the doctrines of the intricate 

"Mr. Fownes' work, although consisting of only a science which it so clearly explains."— Medico- Chi- 

single thick 12mo. volume, includes a notice of almost rurgical Review. 
e=yexy branch cf the subject, nothing of any importance 






LEA & BLANCHARD'S PUBLICATIONS. 



21 



"This is an unpretending, but decidedly valuable 
treatise, on the elements of chemistry, theoretical and 
practical. Dr. Bridges has a perfect idea of what is 
needed, and the preparation of this excellent guide 
should have the countenance of all public instructors, 
and especially those of medical students."— Boston 
Med. $ Surg. Journal. 

" This is a very excellent manual for the use of stu- 
dents and junior practitioners, being sufficiently full 
and complete on the elements of the science, without 
omitting any necessary information, or extending too 
far into detail. It is written in a clear and concise 
style, and illustrated by a sufficient number of well 
executed wood-cuts and diagrams. The Editor has 
executed his task in a creditable manner, and we have 
no doubt the work will prove entirely satisfactory, as 
an introduction to the science of which it treats." — N. 
Y. Journal of Med. $■ Surgery. 

" He has succeeded in comprising the matter of his 
work in 460 duodecimo pages, which, assuredly, is a 
recommendation of the volume as a text-book for stu- 
dents. In this respect it has advantages over any 
treatise which has yet been offered to American stu- 
dents. The difficulty in a text-book of chemistry is to 
treat the subject with sufficient fullness without going 
too much into detail. For students comparatively 
ignorant of chemical science, the larger systems are 
unprofitable companions in their attendance upon lec- 
tures. They need a work of a more elementary cha- 
racter, by which they may be inducted into the first 
principles of the science, and prepared for mastering 



its more abstruse subjects. Such a treatise is the one 
which we have now the pleasure of introducing to our 
readers ; no manual of chemistry with which we have 
met comes so near meeting the wants of the beginner. 
All the prominent truths of the science, up to the pre- 
sent time, will be found given in it with the utmost 
practicable brevity. The style is admirable for its 
conciseness and clearness. Many wood-cuts are 
supplied, by which processes are made intelligible' 
The author expresses regret, that he could not enter 
more largely into organic chemistry, but his details 
will be found to embrace the most important facts in 
that interesting branch of the science. We shall re- 
commend his manual to our class next winter." — The 
Western Journal of Medicine' and Surgery. 

" We are presented with a work, not only compre- 
hensive as regards general principles, but full of prac- 
tical details of the working processes of the scientific 
laboratory; and in addition, it contains numerous 
wood engravings, showing the most useful forms of 
apparatus, with their adjustments and methods of use. 

"The original work having been full and complete, 
as far as the limits of such a volume would permit, 
and on every point brought up to the date of its publi- 
cation (in September last,) the task of the editor has 
been to add any important matter which appeared 
since, and to correct such typographical errors as had 
escaped the author. That this task has been well 
and ably performed, the known zeal and competency 
of Dr. Bridges afford a sufficient guarantee."— Th& 
Medical Examiner. 



GRAHAM'S CHEMISTRY. 



THE ELEfHEiiTS OF CHEMISTRY. 

INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. 

With Numerous Illustrations. 

BY THOMAS GRAHAM, F. R. S. L. and E. D. 

Professor of Chemistry in University College, London, &c. &c. 

WITH NOTES AND ADDITIONS, 

BY ROBERT BRIDGES, M. D., &c. &c. 

In One Vol. Octavo. 

The great advancement recently made in all branches of chemical investigation, ren- 
ders necessary an enlarged work which shall clearly elucidate the numerous discoveries, 
especially in the department connected with organic Chemistry and Physiology, in 
which such gigantic strides have been made during the last few years. The present 
treatise is considered by eminent judges to fulfil these indications, and to be pecu- 
liarly adapted to the necessities of the advanced medical student and practitioner. In 
adapting it to the wants of the American profession, the editor has endeavoured to render 
his portion of the work worthy the exalted reputation of the first chemist of England. 
It is already introduced in many of the Colleges, and has universal approbation. 

Though so recently published, it has been translated into German, by Dr. F. Julius 
Otto, the eminent professor at Brunswick, and has already passed to a second edition. 



22 LEA & BLANCHARD'S PUBLICATIONS. 

A NEW MEDICAL DICTIONARY. 

In one Volume, large 12iu©., now ready, at a low price. 



A DICTIONARY OF 

THE TERMS USED IN MEDICINE 

AND 

THE COLLATERAL SCIENCES; 

By RICHARD D. HOBLYN, A.M., Oxon. 
FIRST AMERICAN, FROM THE SECOND LONDON EDITION. 

REVISED, WITH NUMEROUS ADDITIONS, 

BY ISAAC HAYS, M.D., 

EDITOR OF THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 

Believing that a work of this kind would be useful to the profession in 
this country, the publishers have issued an edition in a neat form for the 
office table, at a low price. Its object is to serve as an introduction to the 
larger and more elaborate Dictionaries, and to assist the student commenc- 
ing the study of Medicine, by presenting in a concise form an explanation 
of the terms most used in Medicine and the collateral sciences, by giving 
the etymology and definition in a manner as simple and clear as possible, 
without going into details ; and bringing up the work to. the present time 
by including the numerous terms lately introduced. This design the author 
has so ably executed as to elicit the highest encomiums of the medical 
press, a few of the testimonies of which are subjoined. 

It has been edited with especial reference to the wants of the American 
practitioner, the native medicinal plants being introduced, with the for- 
mulae for the various officinal preparations; and the whole being made to 
conform to the Pharmacopoeia of the United States. It is now ready in 
one neat royal duodecimo volume of four hundred pages in double co- 
lumns. 

Extract from a Letter from Professor Watts of the College of Physicians and Surgeons, N. York. 

u It is a valuable book for those more advanced in the profession, but especially for 
students of Medicine, and I shall take pleasure in recommending it to my class during 
the coming session.' 7 

OPINIONS OF THE PRESS. 

" We hardly remember to have seen so much valuable matter condensed into 
such a small compass as this little volume presents. The first edition was pub- 
lished in 1835, and the present may be said to be almost re-written, introducing" 
the most recent terms on each subject. The Etymology, Greek, Latin, &c, is 
carefully attended to, and the explanations are clear and precise. We cannot too 
strongly recommend this small and cheap voJume to the library of every student and 
every practitioner." — Medico-Chirurgical Review. 

" We gave a very favourable account of this little book on its first appearance, 
and we have only to repeat the praise with increased emphasis. It is, for its size, 
decidedly the best book of the kind, and ought to be in the possession of every 
student. Its plan is sufficiently comprehensive, and it contains an immense mass 
of necessary information in. a very small compass." — British and Foreign Medi- 
cal Review. 

" A work much wanted, and very ably executed." — London Medical Journal* 

" This compendious volume is well adapted for the use of students. It contains 
a complete glossary of the terms used in medicine — not only those in common 
use, but also the more recent and less familiar names introduced by modern wri- 
ters. The introduction of tabular views of different subjects is at once compre- 
hensive and satisfactory." — Medical Gazette. 

" Concise and ingenious." — Johnson's Medico- Chirur. Journal. 

"It is a very learned, pains-taking, complete, and useful work — a Dictionary 
absolutely necessary in a medical library."-— Spectator, 



LEA & BLANCHARD'S PUBLICATIONS. 23 

KATES? PUBLISHED. 

A NEW EDITION OF 

OARPEITTER'S HUMAN PHYSIOLOGY, 

REVISED AND MUCH IMPROVED. 

PRINCIPLES OF HUMAN PHYSIOLOGY, 

WITH THEIR CHIEF APPLICATIONS TO 

PATHOLOGY, HYGIENE & FORENSIC MEDICINE. 
By WILLIAM B. CARPENTER, M.D., F.R.S., &c. 

SECOND AMERICAN, FROM A NEW AND REVISED LONDON EDITION. 

WITH NOTES AND ADDITIONS, 

BY MEREDITH CLYMER, M.D., &c, 
With Two Hundred and Sixteen Wood-cut and other Illustrations. 

In one octavo volume, of about 650 closely and beautifully printed pages. 

The very rapid sale of a large impression of the first edition is an evidence of the merits of this 
valuable work, and that it has been duly appreciated by the profession of this country. The pub- 
lishers hope that the present edition will be found still more worthy of approbation, not only from 
the additions of the author and editor, but also from its superior execution and the abundance of 
its illustrations. No less than eighty-five wood-cuts and another lithographic plate will be found 
to have been added, affording the most material assistance to the student. 

" We have much satisfaction in declaring our opinion that this work is the best systematic treat- 
ise on physiology in our own language, and the best adapted for the student existing in any lan- 
guage.' 2 — Medico- Chirurgical Review. 



NOW READY. 

A NEW AND IMPROVED EDITION OF 

A SYSTEM OF PRACTICAL SURGERY. 
By WILLIAM FERGUSSON, F.R.S.E. 

Second American Edition, Revised and Improved. 

WITH TWO HUNDRED AND FIFTY-TWO ILLUSTRATIONS FROM DRAWINGS BY BAGG, ENGRAVED EY 
GILBERT, WITH NOTES AND ADDITIONAL ILLUSTRATIONS, 

BY GEORGE W. NORRIS, M.D., &c. 
In one beautiful octavo volume of six hundred and forty large pages. 

The publishers commend to the attention of the profession this new and improved edition of 
Fergusson's standard work, as combining cheapness and elegance, with a clear, sound and practical 
treatment of every subject in surgical science. Neither pains nor expense have been spared to 
make it worthy of the reputation which it has already acquired, and of which the rapid exhaustion 
of the first edition is sufficient evidence. It is extensively used as a text-book in many medical 
colleges throughout the country. 

The object and nature of this volume are thus described by the author : — " The present work 
has not been produced to compete with any already before the Profession; the arrangement, the 
manner in which the subjects have been treated, and the illustrations, are all different from any of 
the kind in the English language. It is not intended to be placed in comparison with the elemen- 
tary systems of Cooper, Burns, Liston, Symes, Lizars, and that excellent epitome of Mr. Druitt.— 
It may with more propriety be likened to the Operative Surgery of Sir C. Bell, and that of Mr. 
Averill, both excellent in their day, or the more modern production of Mr. Hargrave, and the 
Practical Surgery of Mr. Liston. There are subjects treated of in this volume, however, which 
none of these gentlemen have noticed ; and the author is sufficiently sanguine to entertain the idea 
that this work may in some degree assume that relative position in British Surgery, which the 
classical volumes of Velpeau and Malgaigne occupy on the Continent." 

"If we were to say that this volume by Mr. Fergusson, is one excellently adapted to the stu- 
dent, and the yet inexperienced practitioner of surgery, we should restrict unduly its range. It is 
of the kind which every medical man ought to have by him for ready reference, as a guide to the 
prompt treatment of many accidents and injuries, which whilst he hesitates, may be followed by 
incurable defects, and deformities of structure, if not by death itself. In drawing to a close our 
notice of Mr. Fergusson's Practical Surgery, we cannot refrain from again adverting to the nume- 
rous aad beautiful illustrations by wood-cuts, which contribute so admirably to elucidate the de- 
scriptions in the text. Dr. Norris has, as usual, acquitted himself judiciously in his office of 
asnciator. His additions are strictly practical and to the point." — Bulletin of Medical Science^ 



24 LEA & BLANCHARD'S PUBLICATIONS. 

1ASELY PUBLISHED, 
A NEW EDITION OF 

WILSON'S HUMAN" ANATOMY, 

Much Improved. 

GENERAL AND SPECIAL. 

BY ERASMUS WILSOB, 3SI.D., 

Lecturer on Anatomy, London. 
SECOND AMERICAN EDITION, EDITED BY 

PAUL B. GODDARD, A.M., M.D., 

Lecturer on Anatomy and Demonstrator in the University of Pennsylvania, 8^c. 

WITH OVER TWO HUNDRED ILLUSTRATIONS, 
Beautifully Printed from the Second London Edition. 

IN ONE VERY NEAT OCTAVO VOLUME. 
From the Preface to the Second American Edition. 

<e The very rapid sale of the first edition of this work, is evidence of its appreciation by the pro- 
fession, and is most gratifying to the author and American editor. In preparing the present edition 
no pains have been spared to render it as complete a manual of Anatomy for the medical student as 
possible. A chapter on Histology has therefore been prefixed, and a considerable number of new- 
cuts added. Among the latter, are some very fine ones of the nerves which were almost wholly 
omitted from the original work. Great care has also been taken to have this edition correct, and 
the cuts carefully and beautifully worked, and it is confidently believed that it will give satisfaction, 
offering a further inducement to its general use as a Text-book in the various Colleges." 

" Mr. Wilson, before the publication of this work, was very favourably known to the profession 
by his treatise on Practical and Surgical Anatomy ; and, as this is the Second American Edition, 
from the second London Edition, since 1840, any special commendation of the high value of the 
present work, on our part, would be supererogatory. Besides the work has been translated at Ber- 
lin, and overtures were repeatedly made to the London publisher for its reproduction in France.— 
The work is, undoubtedly, a complete system of human anatomy, brought up to the present day. — 
The illustrations are certainly very beautiful, the originals having been expressly designed and exe- 
cuted for this work by the celebrated Bagg of London; and, in the American edition they have 
been copied in a masterly and spirited manner. As a text-book in the various colleges we would 
commend it in the highest terms." — New York Journal of Medicine. 



CHURCHILL'S MIDWIFERY. 

ON THE THEORY AND PRACTICE OF MIDWIFERY, 

BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., 

PHYSICIAN TO THE WESTERN LYING-IN-HOSPITAL, ETC., ETC. 

WITH NOTES AND ADDITIONS 

BY ROBERT HUSTON, M.D., 

Professor in the Jefferson Medical College, &c, &c. 

And One Hundred and Sixteen Illustrations, 

Engraved by Gilbert from Drawings by Bagg and others. 
In one volume, octavo. 
This work commends itself to the notice of the profession from the high reputation of the author 
and editor, and the number and beauty of its illustrations. Besides accurate directions for 
THE PRACTICE OF MIDWIFERY, 
a portion of the work is also devoted to 
THE PHYSIOLOGY AND PATHOLOGY 
connected with that essential branch of medical knowledge. 
" It is impossible to conceive a more useful or elegant manual : the letter-press contains all that 
the practical man can desire ; the illustrations are very numerous, well chosen, and of the most ele- 
gant description, and the work has been brought out at a moderate price." — Provincial Med. Jour. 
(i We expected a first rate production, and we have not been in the least disappointed. Although 
we have many, very many valuable works on tokology, were we reduced to the necessity of pos- 
sessing but one, and permitted to choose, we would unhesitatingly take Churchill." — Western Med. 
and Surg. Journal. 

This work is printed, illustrated and bound to match Carpenter's Physiology, 
Fergusson's Surgery and Wilson's Anatomy, and the whole, with Watson's Prac- 
tice, Pereira's Materia Medica and Graham's Chemistry, are extensively used in 
the various colleges. 



LEA & BLANCHARD'S PUBLICATIONS. 25 



PEKEIRA'S MATERIA MEDICA. 

WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. 
A NEW EDITION- STOW READY. 

THE ELEMENTS OF MATERIaIsEBICA AND THERAPEUTICS. 

COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- 
SITION, EFFECTS, AND USES OF MEDICINES. 

BY JONATHAN PEREIRA, M.D., F.R.S. and L. S. 

Member of the Society of Pharmacy of Paris; Examiner in Materia Medica and Pharmacy of the 

University of London; Lecturer on Materia Medica at the London Hospital, &c, &c. 

Second American, from the last London Edition, enlarged and improved. With Notes and Additions 

BY JOSEPH CARSON, M.D., 

In two volumes, octavo. 

Part I, contains the General Action and Classification of Medicines and the Mineral Materia Me- 
dica. Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the 
Processes of the Pharmacopoeias, a tabular view of the History of the Materia Medica, from the 
earliest times to the present day, and a very copious index. From the last London Edition, which 
has been thoroughly revised, with the Introduction of the Processes of the New Edinburgh Phar- 
macopoeia, and containing additional articles on Mental Remedies, Light, Heat, Cold, Electricity, 
Magnetism, Exercise, Dietetics and Climate, and many additional Wood-cuts, Illustrative of Phar- 
maceutical Operations, Crystallography, Shape and Organization of the Feculas of Commerce, and 
the Natural History of the Materia Medica. 

The object of the author has been to supply the Medical Student with a Class Book on Materia 
Medica, containing a faithful outline of this Department of Medicine, which should embrace a con- 
cise account of the most important discoveries in Natural History, Chemistry, Physiology, and The- 
rapeutics, in so far as they pertain to Pharmacology, and treat the subjects in the order of their 
natural historical relations. 

The opportunity has been embraced in passing this New Edition through the hands of the Editor, 
Dr. Carson, to make such additions as were required to the day, and to correct such errors as had 
passed the inspection of the Author and Editor of the first edition. It may now be considered as 
worthy the entire confidence of the Physician and Pharmaceutist as a standard work. 

This great Library or Cyclopaedia of Materia Medica has been fully revised, the errors corrected, 
and numerous additions made by DR. JOSEPH CARSON, Professor of Materia Medica and Phar- 
macy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and 
closely printed pages. It may be fully relied upon as a permanent and standard work for the coun- 
try — embodying, as it does, full references to the U. S. Pharmacopoeia and an account of the Medi- 
cal Plants indigenous to the United States. 

" An Encyclopaedia of knowledge in that department of medical science — by the common con 
sent of the profession the most elaborate and scientific Treatise on Materia Medica in our lan- 
guage." — Western Journal of Medicine and Surgery. 

" Upon looking over the American edition of the Materia Medica of Dr. Pereira, we have seen no 
reason to alter the very favourable opinion expressed in former numbers of this Journal. (See Am. 
Med. Journal, XXIV, 413, and N. S., I. 192.) We are glad to perceive that it has been repub- 
lished here without curtailment. Independently of the injustice done to an author by putting forth 
an abbreviated edition of his works, without his superintendence or consent, such a course would 
in the present instance have been unjust also to the public, as one of the chief recommendations 
of Dr. Pereira's treatise is its almost encyclopedic copiousness. We turn to its pages with 
the expectation of finding information upon all points of Materia Medica, and would have good 
reason to complain were this expectation disappointed by the scissors of an American Editor. 
Indeed, the main defect of the work, in relation to American practitioners, was the want of 
sufficient notices of the medicines and preparations peculiar to this country. In the edition 
before us this defect has been supplied by the Editor, Dr. Joseph Carson, who was, in a high 
degree qualified for the task, and, so far as we are able to judge from a very partial perusal, has 
executed it with judgment and fidelity. The nomenclature and preparations of our national 
standard have been introduced when wanting in the English edition, and many of our medical 
plants, either briefly noticed or altogether omitted by Dr. Pereira, because unknown in Europe, 
have been sufficiently described. We must repeat the expression of our opinion that the work will 
be found an invaluable storehouse of information for the physician and medical teacher, and con- 
gratulate the profession of this country that it is now placed within their reach." — Am. Med. Journ. 

" To say that these volumes on Materia Medica and Therapeutics, by Dr. Pereira, are comprehen- 
sive, learned and practical, and adapted to the requirements of the practitioner, the advanced stu- 
dent, as well as the apothecary, expresses the opinion, we will venture to assert, of nearly every 
judge of the subject, but fails to convey to those who are not acquainted with the work, a definite 
idea of its really distinctive traits, according to our general usage, we shall, therefore, proceed to 
place these before our readers, so that they may know what it is, and why we praise. Valuable 
and various as are the contents of the volumes of Dr. Pereira, we have no hesitation in assert- 
ing, despite the adverse cant in some quarters on the subject of the American additions to English 
works, that the value of the present edition is enhanced by the appropriate contributions of 
Dr. Carson, who has introc]uC e ^ succinct histories of the most important indigenous medicines ©f 
the United States Pharmacopeia/.'-- Sekqt Med. Library. 



LEA & BLANCHARD'S PUBLICATIONS. 



THE SURGICAL WORKS JF SIR ASTLEY COOPER, 

LEA & BLANCH ARD have now completed the last volume of the illustrated works of Sir Astley Cooper. 
They form an elegant series; the works on Hernia, the Testis, the Thymus Gland and the Breast, being print- 
ed, illustrated and bound to match, in imperial octavo with numerous Li THOGRAPHIC PLATES, while the 
Treatise on Dislocations is in a neat medium octavo form, with NUMEROUS WOOD-CUTS similar to the 
last London Edition. 



COOPER ON THE 

ANATOMY AND DISEASES OF THE BREAST, fa 



just rujsiLisBLmn. 



This large and beautiful volume contains THE ANATOMY OF THE BREAST; 

THE COMPARATIVE ANATOMY OF THE MAMMARY GLANDS; 

ILLUSTRATIONS OF THE DISEASES OF THE BREAST; 

And Twenty-five Miscellaneous Surgical Papers, now first published in a collected form. 

By SIR ASTLEY COOPER, Bart., F.R.S.,&c. 

The whole in one large imperial octavo volume, illustrated with two hundred and fifty -two. figures on 
thirty six Lithographic Plates ; well and strongly bound* 

SIR ASTLEY G0OPER ON HERNIA, 

With One Hundred and Thirty Figures in Lithography, 

THE AMIOIY AND SUMIOAL TREATMEIT DP 



By Sir ASTLEY COOPER, Bart. 
Edited by C. Aston Key, Surgeon to Guy's Hospital, &c. 

This important work of Sir Astley is printed from the authorized second edition, published in London, in 
large super-royal folio, and edited by his nephew, Professor Key. Jt contains all the Plates and all the Let- 
terpress—there are no omissions, interpolations, or modifications— it is the complete work in 

One Large Imperial Octavo Volume. 
WITH OVER ISO FIGURES ON 28 PLATES, AND OVER 400 LARGE PAGES OF LETTERPRESS. 

The correctness of the Plates is guaranteed by a revision and close examination under the eye of a distin- 
guished Surgeon of this city. 

ANOTHER VOLUME OF THE SERIES CONTAINS HIS TREATISE 

ON THE STRUCTURE AND DISEASES OF THE TESTIS, 

Illustrated by 120 Figures. From the Second London Edition. 
By BRANSBY B. COOPER, Esq. 

AND ALSO 

ON THE ANATOMY OF THE THYMUS GLAND. 

Illustrated by 57 Figures. 

The two works together in one beautiful imperial octavo volume, illustrated with twenty-nine plates in > 
the best style of lithography, and printed and bound to match. & 



C00FER ON FRAGT1IHES AND DISLOCATIONS, 

WITH NUMEROUS WOOD-CUTS. 
A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. By SIR ASTLEY COOPER, 

Bart., F. R. S., Sergeant Surgeon to the King, &c. 
A new edition much enlarged; edited by BRANSBY COOPER, F.R.S., Surgeon to Guy's Hospital, with ad- 
ditional Observations from Professor John C. Warren, of Boston. With numerous engravings on wood, 
after designs by Bagg, a memoir and a splendid portrait of Sir Astley. In one octavo volume. 
The peculiar value of this, as of all Sir Astley Cooper's works, consists in its eminently practical character. 
His nephew, Bransby B. Cooper, from his own experience, has added a number of cases. Besides this, Sir 
Astlev left behind him very considerable additions in MS. for the express purpose of being introduced into this 
edition. The volume is embellished with ONE HUNDRED AND THIRTY-THREE WOOD-CUTS, and 
contains the history of no less than three hundred and sixty-one cases, thus embodying the records of a life of 
practice of the Author and his various editors. There are also additional Observations from notes furnished 
bv John C. Warren, M.D., the Professor of Anatomy and Surgery in Harvard University. 

"" After the fiat of the profession, it would be absurd in us to eulogize Sir Astley Cooper's work on Fractures 
and Dislocations. It is a national one, and will probably subsist as long as English surgery."— Medico- Chirur- 
gical Review. 



LEA & BLANCHARD'S PUBLICATIONS. ST 

LATELY PUBLISHED. 

MEIGS' TRANSLATION 

x OF 

COLO^BAT 01 L'iSEBE ON THE DISEASES OF FEMALES. 
A TREATISE ON THE DISEASES OF FEMALES, 

AND ON 

THE SPECIAL HYGIENE OF THEIR SEX. 

WITH NUMEROUS WOOD-CUTS. 
BY COLOMBAT DE L'ISERE, M.D., 

•Chevalier of the Legion of Honor; late Surgeon to the Hospital of the Rue de Valois, devoted to the Diseases of 

Females, #c, 8ec 

TRANSLATED, WITH MANY NOTES AND ADDITIONS, 
By C. D. MEIGS, M.D., 

Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, 8rc. Src. 
In One Large Volume, 870. 
« We are satisfied it is destined to take the front rank in this department of medical science; it is 
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the celebrated practitioners of ancient and modern times. The Editor and Translator has per- 
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yet elegant. More than one hundred pages of original matter have been incorporated in the text, 
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ASHWELL ON THE DISEASES OF FEMALES, 

A PRACTICAL TREATISE ON THE 

DISEASES PECULIAR TO WOMEN, 

ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. 
By SAMUEL ASHWELL, M.D., 

Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guy's Hospital, &c. 

WITH ADDITIONS, 
By PAUL BECK GODDARD, M.D. 
T' The whole complete in one Large Octavo Volume. 

" The most able, and certainly the most standard and practical work on female diseases that we 
have yet seen." — Medico- Chirurgical Review. 



A NEW EDITION OF CHUKCHILL ON FEMALES. 

THE DISEASES OF FEMALES, 

INCLUDING THOSE OF " 

By FLEETWOOD CHURCHILL, M.D., 

Author of -Theory and Practice of Midwifery," &c, &c. 
THIRD AMERICAN, FROM THE SECOND LONDON EDITION. 

With Illustrations. Edited with Notes, 

By ROBERT M. HUSTON, M.D., &c, fire. 
In One Volume, 8vo. 

" In complying with the demand of the profession in this country for a third edition, the Editor 
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All the additional references and illustrations contained in the English copy, are retained in this.'' 



TAYLOR'S JURISPRUDENCE. 

MEDICAL JURISPRUDENCE, 

BY ALFRED S. TAYLOR. 

Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital. 

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BY R. E. GRIFFITH, M.D. 
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CONDIE ON CHILDREN. 



A PRACTICAL TREATISE 

ON 

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BY D. FRANCIS CONDIE, M. D. 

Fellow of the College of Physicians; Member of the American Philosophical Society, &c. &c. 

In one volume, octavo. 

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THOMSON ON THE SICK ROOM. 



THE DOMESTIC MANAGEMENT OF THE SICK ROOM, 

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WILLIAMS' PATHOLOGY. 

PRINCIPLES OF MEDICINE, 

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GENERAL PATHOLOGY AND THERAPEUTICS, and a general view of ETIOLOGY, 

NOSOLOGY, SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. 

BY CHARLES J. B. WILLIAMS, M.D., F. K. S., 

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Lecturer on the Institutes of Medicine, &c. &c. 

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OUTLINES OF PATHOLOGY AND PRACTICE OF MEDICINE. 

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30 



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NEW WORKS AND NEW EDITIONS, 

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LISTON AND MUTTER'S 

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1 



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subjected it to a thorough revision, and has endeavoured to so modify the work as to make 
it a more complete and exact exponent of the present state of knowledge on the important 
subjects of which it treats. The favour with which the former editions were received, 
demanded that the present should be rendered still more worthy of the patronage of the 
profession, and this alteration will be found not only in the matter of the volumes, but also 
in the numerous illustrations introduced, and the general improvement in the appearance 
of the work. 

LIST OF ILLUSTRATIONS. 





VOL. I. 






25. 


Chenopodium Anthelminti- 


53. 


Conium maculatum. 




cum. 


54. 


Humulus Lupulus. 


26. 


Spigelia Marilandica. 


55. 


Dried lupulinic grain with its 


27. 


Nephrodium Filix mas. 




hilum magnified. 


23. 


Punica granatum. 


56. 


Cannabis sativa. 


29, 


30. Inhaling Boules. 


57. 


Lycopus Virginicus. 


31. 


Balsamadendron Myrrha. 


58. 


Strychnos Nux Vomica. 


32. 


Acacia Arabica. 


59. 


Ruta graveolens. 


33. 


OJea Europaea. 


60. 


Secale cornutum. 


34. 


Saccharum officinarum. 


61. 


Cinnamomum Zeylanicum. 


35 


Linum usitatissimum. 


62. 


Cardamom. 


36. 


Astragalus verus. 


63. 


Cariophyllus aromaticus. 


37. 


Cetraria Islandica. 


64. 


Fceniculum vulgare. 


38. 


Fucus vesiculosus. 


65. 


Monarda coccinea. 


39. 


Inhaler. 


66. 


Hedeoma pulegioides. 


40. 


Cantharides. 


67. 


Myristica moschata. 


41. 


Leontodon Taraxacum. 


68. 


Nutmeg in the shell surround- 


42. 


Erigeron Philadelphicum. 




ed by the mace. 


43. 


Arbutus Uva ursi. 


69. 


Gaultheria procumbens. 


44. 


Eupatorium perfoliatum. 


70. 


Juniperus communis. 


45. 


Asclepias tuberosa. 


71. 


Citrus Aurantium. 


46. 


Arum triphyllum. 


72. 


Laurus Camphora. 


47. 


Carthamus tinctorius. 


73. 


Drymis Winteri. 


48. 


Warm-bath. 


74. 


Acorus Calamus. 


49. 


Hip-bath. 


75. 


Piper nigrum. 


50. 


Foot-bath. 


76. 


Electrical Apparatus for Me- 


51. 


Hyoscyamus Niger. 




dical purposes. 


52. 


Datura Stramonium. 
VOL. II. 






17. 


Dyospyros Virginiana. 


32. 


Particles of white East India 


IS. 


Heuchera acerifolia. 




Arrow-root. 


19. 


Spiraea tomentosa. 


33. 


Particles of West India Ar- 


20. 


Statice Caroliniana. 




row-root. 


21. 


Colchicum autumnale. 


34. 


Particles of Tous-les-mois. 


22. 


Veratrum Album. Ver. Al- 


35. 


Particles of Potato starch seen 




biflorum. 




by the microscope. 


23. 


Cimicifusra racemosa. 


36. 


Janipha Manihot. 

Particles of Tapioca as seen 


24,25. Shower-bath. 


37. 


26. 


Abies excelsa. 




by the microscope. 


27. 


Ranunculus acris. 


38. 


Sagus Rumphii. 
Particles of Sago-meal. 


28. 


Aralia nudicaulis. 


39. 


29 


Solanum dulcamara. 


40. 


Particles of Potato sago. 


30. 


Tacca pinnatifida. 


41. 


Cycas revoluta or the Japan 


31. 


Particles of Tahiti Arrow- 




Sago-tree. 




root. 


42. 


Avena Sativa. 






43. 


Particles of Wheat Starch. 



1. Cephaglis Ipecacuanha. 

2. Brown Ipecacuanha root. 

3. Striated Ipecacuanha root — 
Undulated Ipecacuanha root. 

4. Ionidium Ipecacuanha root. 

5. Gillenia stipulacea. 

6. Lobelia inflata. 

7. Sanguinaria Canadensis. 

8. Apocynum Androsaemifolium. 

9. Erythronium Americanum. 

10. Euphorbia corollata. 

11. Ficus Carica. 

12. Ricinis communis. 

13. Rheum palmatum. 

14. Rheum compactum. 

15. Aloe Socotorina. 

16. Legume and leaflet of Acute 
leaved Alexandrian Senna. 

17. Legume and leaflet of C.obo- 

vata. 

18. Tinnevelly Senna. 

19. Cassia Marilandica. 

20. Podophyllum. 

21. Hebradendron cambogio'ides 

22. Momordica Elaterium. 

23. Apocynum cannabinum. 

24. Convolvulus panduratus. 



1. Cocculus palmatus. (Male 
plant.) 

2. Gentiana Catesbsei. 

3. Frasera Walteri. 

4. Sabbatia angularis. 

5. Coptis trifolia. 

6. Aletris farinosa. 

7. Aristolochia serpentaria. 

8. Asarum Canadense. 

9. Anthemis Cotula. 

10. Magnolia glauca. 

11. Magnolia macrophylla. 

12. Geum Virginianum. 

13. Hepatica Americana. 

14. Indigo. 

15. Cornus Florida. 

16. Liriodendron tulipifera. 

" Our junior brethren in America will find in these volumes of Professor Dunglison, a ' Thesaurus 
Medicaminum,' more valuable than a large purse of gold."—Medico-Chirurgical Review for Jan., 1845. 

2 



LEA & BLANCHARD'S LATE PUBLICATIONS. 



CHELIUS'S SYSTEM OF SURGERY. 



A SYSTEM OF SURGERY, 

BY J. M. CHELIUS, 

DOCTOR IN MEDICINE AND SURGERY, PUBLIC PROFESSOR OF GENERAL AND OPHTHALMIC 
SURGERY, ETC. ETC., IN THE UNIVERSITY OF HEIDELBERG. 

TRANSLATED FROM THE GERMAN, 

AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, 

BY JOHN F. SOUTH, 

SURGEON TO ST. THOMAS'S HOSPITAL. 

EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES, 

BY GEORGE W. NORRIS ; M.D. 

PUBLISHING IN NUMBERS, AT FIFTY CENTS EACH. 

EIGHT NUMBERS ARE NOW READY. 

That this work should have passed to six editions in Germany, and have been translated into no 
less than seven languages, is sufficient proof of its value. It contains what is, perhaps, embraced to 
an equal extent in no oiher work on the subject now before the public, a complete System of Surgery, 
both in its principles and practice. The additions of the translator, Mr. South, are very numerous, 
bringing the work up to the very day of publication, and embodying whatever may have been omitted 
by the author respecting English Surgery : while Dr. Norris will take equal care in representing the 
state of the science in America. 

"Judging from a single number only of this work, we have no hesitation in saying that, if the remain- 
ing portions correspond at all with the first, it will be by far the most complete and scientific system of 
surgery in the English language. We have, indeed, seen no work which so nearly comes up to our 
idea of what such a production should be, both as a practical guide and as a work of reference, as 
this; and the fact that it has passed through six editions in Germany, and been translated into seven 
languages, is sufficiently convincing proof of its value. It is methodical and concise, clear and accu- 
rate; omitting all minor details and fruitless speculations, it gives us all the information we want in 
the shortest and simplest form." — The New York Journal of Medicine. 

"The scope of Professor Chelius's Manual is indicated by its title: it professes to treat, systemati- 
cally, of the science and art of surgery, but within such compass as to render the work an appropriate 
introduction and companion to his lectures. The care, however, which has been bestowed upon its 
construction, and the labour which its research evinces, would be ill-repaid were it confined to this 
sphere; and we may conscientiously say that we know of no Manual of surgery, on the whole, more 
deserving of public confidence, or more valuable as a guide and refresher to the young practitioner. 
It is not our intention at present critically to analyze Mr. South's labours; but we should be guilty 
of an injustice to him and to our readers if we did not cordially recommend his work as having fair 
promise of forming, what it is the translator's ambition it should be, a sound and comprehensive 
system of practical surgery. The notes and text are so intermingled as to render it continuously 
readable, without presenting those abrupt transitions which are so disagreeable in many works simi- 
larly arranged. The faults of omission. &c, at which we have hinted in our comments on the first 
chapter of our author's work, (viz., that on 'Inflammation,') have been amply compensated by the 
copious and excellent digest of his translator and annotator, who is justly proud of availing himself of 
the labours of our own countrymen in this department of pathology, while he gives their due meed of 
notice and respect to the contributions of our continental brethren. The references which are given 
to original works have evidently been carefully collated, and will be found of great value to the 
student and practitioner who may wish for more copious information on any particular branch of 
surgery; and the practical remarks and illustrations with which the work abounds, are a good 
guarantee of the translator's ability to do justice to his task, at the same time that they prove that Mr. 
South has not failed to avail himself industriously of the large opportunities which his hospital appoint- 
ment has afforded him." — The British and Foreign Medical Review. 

"We will, therefore, content ourselves for the present with directing the attention of the profession 
to it, as being the most complete system of surgery in any language, and one that is of equal utility as 
a practical guide and as a work of reference. The fact of its having reached six editions in Germany, 
and of its having been translated into seven languages, are more convincing proofs of its value than 
anything that we can say. Mr. South has performed his task with much judgment, and has certainly 
made a most useful addition to the medical literature of this country by rendering Chelius's work into 
English."— The Lancet. 

3 



LEA & BLANCHARD'S LATE PUBLICATIONS. 



COMPENDIUM OF CHAPMAN'S LECTURES, 

A COMPENDIUM OF LECTURES 

o]sr THE 

THEORY AND PRACTICE OF MEDICINE. 

DELIVERED BY PROFESSOR CHAPMAN IN THE UNIVERSITY OF 
PENNSYLVANIA. 

PREPARED, WITH PERMISSION, FROM DR. CHAPMAN'S MANU- 
SCRIPTS, AND PUBLISHED WITH HIS APPROBATION, 

BY N. D. BENEDICT, M. D. 

IN ONE VERY NEAT OCTAVO VOLUME. 

CONTENTS. 

Remarks on the Classification of Diseases — Fever in General — Intermittent Fever — Remit- 
tent Fever — Continued Fever, (Mild, Intermediate, and Extreme Forms) — Yellow Fever 
—Endemic Pneumonic, or Spotted Fever — Diseases of the Heart and Blood-vessels, (In- 
flammatory, Organic, and Nervous) — Acute Carditis, Pericarditis, and Endocarditis — Chro- 
nic Carditis, Pericarditis, and Endocarditis — Hypertrophy of the Heart — Dilatation of the 
Heart — Atrophy of the Heart — Rupture of the Heart — Affections of the Valves of the 
Heart — Palpitations — Acute Arteritis — Degenerations of Arteries — Aneurism of Arteries 
— Phlebitis — Acute Inflammation of the Throat — Chronic Inflammation of the Throat — 
Dysphagia — Parotitis — Dysentery, (Inflammatory) — Dysentery, (Congestive) — Diarrhoea — 
Cholera Morbus — Cholera Infantum — Flatulent Colic — Bilious Colic — Colica Pictonum — 
Acute Peritonitis — Chronic Peritonitis — Acute Catarrh — Catarrhus iEstivus — Chronic Ca- 
tarrh — Acute Bronchitis — Chronic Bronchitis — Catarrhus Senilis — Acute Infantile Bron- 
chitis — Chronic Infantile Bronchitis — Croup — Acute Infantile Asthma — Whooping-Cough 
— Acute Laryngitis — Chronic Laryngitis — Pleuropneumonia — Congestive Pneumonia — 
Chronic Pleurisy and Pneumonia — 'Apoplexy — Palsy — Epilepsy — Hysteria — Chorea — 
Neuralgia — Diabetes. 

It will be seen that this work is entirely distinct from the volumes of Dr. Chapman on Eruptive Fe- 
vers, &c, and on Thoracic and Abdominal Viscera. All the works are printed and bound to match. 

BIRD ON URINARY DEPOSITS. 
URINARY DEPOSITS, 

THEIR DIAGNOSIS, PATHOLOGY AND THERAPEUTICAL 
INDICATIONS. 

BY GOLDING BIRD, A.M., M. D., &c. 

In One Octavo Volume, Cloth, with Cuts. 

"One of the best fruits of this 'revival' in urinary pathology is the work of Dr. Golding Bird, 
which we are about introducing to the notice of our readers. ' 

"In 1843 Dr, Bird delivered a course of lectures on the diagnosis and pathology of urinary sedi- 
ments. They were published in the London Medical Gazette, attracted much attention at the time, 
and were subsequently translated into German. These lectures form the groundwork of the present 
publication, though much extended and nearly rewritten. 

" From the space which we have given to the consideration of this little volume, our readers will 
naturally infer the exalted opinion we entertain of it. Yet we fear we have still conveyed a very 
inadequate notion of its merits. Where almost everything is of value, it is difficult to select or con- 
dense. Such of our readers as wish to increase their store of practical knowledge, and enlarge the 
sphere of their usefulness, we refer to the volume itself, and recommend its possession. We now 
take leave of Dr. Bird with an expression of great readiness to meet him again in the same, or some 
analogous line of investigation." — American Medical Journal. 

" The author of this volume is at once a chemist skilled in analysis, and a practitioner who has 
for years carefully noted diseases at the bedside. It is therefore manifest, that he is qualified in an 
uncommon degree to discuss the subject of urinary deposits, in which the phenomena belong as much 
to chemistry as to pathology. Such are the labourers from whom science is likely to derive the most 
valuable results, as to all the pathological conditions which involve chemical reactions. The mere 
chemist is not competent to the task of unfolding them ; and the pathologist without the tests and 
reagents of the laboratory, is unable to account for the series of changes. The union of the two, as it 
is found in Dr. Bird, is indispensable to a successful prosecution of such researches. It is as a manual 
for the practitioner in urinary affections that he presents his work to the profession, and in that cha- 
racter it has the highest claims to our attention. Its matter is condensed, and so arranged, that ready 
reference may be made to any topic."— The Western Journal of Medicine arid Surgery. 

4 



LEA & BLANCHARD'S LATE PUBLICATIONS. 



SIMON'S CHEMISTRY OF MAN. 
ANIMAL CHEMISTRY. 

WITH REFERENCE TO THE PHYSIOLOGY AND PATHOLOGY OF MAN. 
BY DR. J. FRANZ SIMON. 

TRANSLATED AND EDITED BY 
GEORGE E. DAY, M.A. & L.M. Cantab., &c. 

With Plates, in One Volume, 8vo. 

u A work that obtained for its author a European reputation, and is universally regarded 
as by far the most complete treatise that has yet appeared on Physiological Chemistry." — 
Editor's Preface. 

"No treatise on physiological chemistry approaches, in fullness and accuracy of detail, 
the work which stands at the head of this article. It is the production of a man of true 
German assiduity, who has added to his own researches the results of the labours of nearly 
every other inquirer in this interesting branch of science. The death of such a labourer, 
which is mentioned in the preface to the work as having occurred prematurely in 1842, is 
indeed a calamity to science. He had hardly reached the middle term of life, and yet had 
made himself known all over Europe, and in our country, where his name has been 
familiar for several years as among the most successful of the cultivators of the chemistry 

of man It is a vast repository of facts, to which the teacher and student may refer 

with equal satisfaction." — The Western Journal of Medicine and Surgery. 

" Several reasons combine to render Dr. Simon's work peculiarly valuable. In the first 
place, the author evidently understands his subject, and discusses it with great ability; in 
the next place, his opinions have been formed, in a great measure, from original investiga- 
tions ; and, lastly, he seems to have no theories beyond facts — no dogmas to sustain at the 
expense of truth and principle ; but he enters upon the investigation like a true philoso- 
pher, and the result is such as we have seen." — The Western Lancet. 

BUDD ON THE L IYER. 



ON DISEASES OF THE LIVER. 

BY GEORGE BUDD, M.D., F.R.S., &c. 

WITH 

WOOD-CUTS AND COLOURED PLATES, 

IN THE FIRST STYLE OF ART. 
In One Octavo Volume, Sheep. 

" We cannot too strongly recommend the diligent study of this volume. The work 
cannot fail to rank the name of its author among the most enlightened pathologists and 
soundest practitioners of the day." — Medico- Chirurgical Review. 

" With the new year, Messrs. Lea & Blanchard have brought out one of those sterling 
works on medicine which it refreshes one to examine. It is a sound, practical guide in 
every-day practice, and opportune, from the circumstance that it does not interfere with 
any recent publication. Those only who have felt how difficult it is to decide, or rather 
determine with certainty upon the true condition of the liver, under some indications of 
the system, can appreciate a treatise like this." — Boston Med. and Surg. Journal. 

DURLACHER oF^ORNsTbUNIONS, ETC, 

A TREATISE 0N~~C0RNS, BUNIONS, 

THE DISEASES OF THE NAILS, AND THE GENERAL 
MANAGEMENT OF THE FEET. 

By LEWIS DURLACHER, 

SURGEON CHTBOPODIST, BI SPECIAL APPOINTMENT, TO THE Q/CTEEN. 

In One small Duodecimo Volume, Cloth. 

"These important subjects are in this work lifted above the quackery which has generally in- 
vested them, and we find them treated with evident marks of science and education."— North Am. 

5 



LEA & BLANCHARD'S LATE PUBLICATIONS. 



HUGHES ON THE LUNGS AND HEART. 

CLINICAL INTRODUCTION TO THE PRACTICE OF 
AUSCULTATION, 

AND OTHER MODES OF PHYSICAL DIAGNOSIS. 

INTENDED TO SIMPLIFY THE STUDY OF 

THE DISEASES OF THE HEART AND LUNGS. 

By H. M. HUGHES, M. D., &c. 

In One Duodecimo Volume, (with a Plate.) 

CHURCHI^ 

WITH NUMEROUS ADDITIONS. 

NEW EDITION, JUST PUBLISHED. 
L. & B. have just issued a new edition of this valuable and standard work on the Theory and 
Practice of Midwifery, edited by Huston, in One Octavo Volume, well bound, with numerous illus- 
trations. 

ALSOrLATElTFp 

NEW EDITIONS OF 

PEREIEA'S MATERIA MEDICA. 

REVISED, WITH ADDITIONS, BY CARSON. 

In Two Large Octavo Volumes, many Cuts, 

AND OF 

WATSON'S PRACTICE OF PHYSIC, 

EDITED BY CONDIE, 
IN ONE OCTAVO VOLUME, 

Of nearly Eleven Hundred Large Pages, bound in strong Leather, with raised bands. 

^earlFreadyT 
KIRBY & SPENCE'S ENTOMOLOGY, 

AN INTRODUCTION TO ENTOMOLOGY, 

OR ELEMENTS OF THE 

NATURAL HISTORY OF INSECTS; 

COMPRISING AN ACCOUNT OF 

NOXIOUS AND USEFUL INSECTS, 

OF THEIR 

metamorphoses, food, stratagems, habita- 
tions, SOCIETIES, MOTIONS, NOISES, HYBER- 
NATION, INSTINCT, &c. &c. 

WITH PLATES. 

By WILLIAM KIRBY, M.A., F.R.S. & L. S., &c. &c, 

And WILLIAM SPENCE, Esq., F. R. S. & L. S. 

From the Sixth London Edition, Corrected, and considerably Enlarged. 

IN ONE LARGE OCTAVO VOLUME. 

6 



i 



LEA & BLANCHARD'S LATE PUBLICATIONS. 



LATELY PUBLISHED, A NEW AND HUCH IMPROVED EDITION OF 
DRUITT'S _SURGERY. 

THE 

PRINCIPLES AND PRACTICE OF MODERN SURGERY, 

By ROBERT DRUITT, Surgeon. 
FROM THE THIRD LONDON EDITION. 

ILLUSTRATED BY ONE HUNDRED AND FIFTY-THREE WOOD ENGRAVINGS. 
WITH NOTES AND COMMENTS, 

By JOSHUA B. FLINT, M. M., S. S. 

In One Volume, Octavo, 

" An unsurpassable compendium not only of surgical but of medical practice." — London Med. Gaz. 
A NEW AND IMPROVED EDITION OP 

FERGUSSON'S OPERATIVE SURGERY. 
A SYSTEM OF PRACTICAL SURGERY. 

BY WILLIAM FERGUSSON, F. R. S. E. 
SECOND AMERICAN EDITION, REVISED AND IMPROVED, 

With two hundred and fifty-two Illustrations from drawings by Bagg, engraved by Gilbert. 

WITH NOTES AND ADDITIONAL ILLUSTRATIONS. 
BY GEORGE W. NORRIS, M. D. 

In one beautiful octavo volume of six hundred and forty large pages. 
The publishers commend to the attention of the profession this new and improved edition of Fer- 
gusson's standard work, as combining cheapness and elegance, with a clear, sound, and practical 
treatment of every subject in surgical science. Neither pains nor expense have been spared to make 
it worthy of the reputation which it has already acquired, and of which the rapid exhaustion of the 
first edition is sufficient evidence. It is extensively used as a text-book in many medical colleges 
throughout the country. 

SIR ASTLEY COOPER^SURGICAL WORKS. 

COOPER ON THE ANATOMY AND DISEASES OF THE BREAST. 

TOGETHER WITH 

TWENTY-FIVE MISCELLANEOUS SURGICAL PAPERS: 

NOW FIRST PUBLISHED IN A COLLECTIVE^ FORM. 

IN ONE LARGE IMPERIAL OCTAVO VOLUME. 

With 252 Figures on 36 Plates. 

COOPETWllERNrA. 

IN ONE LARGE IMPERIAL OCTAVO VOLUME. 

With over 130 Figures on 26 Plates. 

COOPER ON THE~TES^^ GLAND. 

ILLUSTRATED WITH 177 FIGURES ON 27 PLATES. 

In One Imperial Octavo Volume. 

COOPER ON FRACTURES AND DISLOCATIONS. 

WITH 133 ILLUSTRATIONS ON WOOD. 
In one neat Octavo Volume. 

7 



LEA & BLANCHARD'S LATE PUBLICATIONS. 



BKODIE'S SURGICAL WORKS. 

BRODIE' S SURGICAL LECTURES. 
NOW READY, 

CLINICAL LECTURES 

ON 

SURGERY. 
IN ONE NEAT OCTAVO VOLUME. 

These Lectures, in passing through the columns of "The Medical 
News," during the last year, have received the unanimous approbation of 
the profession in this country, and will no doubt be eagerly sought for in 
their complete state. 

BRODIE ON URINARY ORGANS. 

LECTURES 

ON THE 

DISEASES OF THE URINARY ORGANS. 

FROM THE THIRD LONDON EDITION. 

WITH ALTERATIONS AND ADDITIONS. 

In one small octavo volume, cloth. 
This work has throughout been entirely revised, some of the author's 
views have been modified, and a considerable proportion of new matter has 
been added, among which is a lecture on the Operation of Lithotomy. 



BRODIE ON THE JOINTS. 

PATHOLOGICAL AND SURGICAL OBSERVATIONS 

ON THE 

DISEASES OF THE JOINTS. 

FROM THE FOURTH LONDON EDITION. 

WITH THE AUTHOR'S ALTERATIONS AND ADDITIONS. 

In one small octavo volume, cloth. 
* To both the practical physician and the student, then, this little volume 
will be one of much service, inasmuch as we have here a condensed view 
of these complicated subjects thoroughly investigated by the aid of the light 
afforded by modern Pathological Surgery." — N. Y. Journal of Medicine. 



THESE WORKS FORM A PART OF 

SIR BENJAMIN BRODIE'S 

LECTURES, ILLUSTRATIVE OF 

VARIOUS SUBJECTS IN PATHOLOGY AND SURGERY, 

The remainder of which will be issued. 
8 



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